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C0FOTGKT DEPOSIT. 



PRACTICAL TUBERCULOSIS 



PRACTICAL TUBERCULOSIS 

A BOOK FOR THE GENERAL 

PRACTITIONER AND 

THOSE INTERESTED IN TUBERCULOSIS 



BY 
HERBERT F. GAMMONS, M.D., 

Superintendent, Woodlawn Sanatorium, Dallas, Texas; Assistant Instructor 
in Clinical Medicine, Baylor Medical College, Dallas, Texas; Formerly- 
Resident Physician, Cullis Consumptives' Home, Dorchester, Mass.; 
Assistant Physician, Massachusetts State Sanatorium, Rut- 
land, Mass.; Assistant Superintendent, Connecticut 
State Sanatorium, Meriden, Conn.; First Assistant 
Physician, Texas State Tuberculosis Sanato- 
rium, Carlsbad, Texas; and Superin- 
tendent, Deerwood Sanatorium, 
Deerwood, Minn. 



Introduction By 

j. b. Mcknight, m.d., 

Superintendent and Medical Director, Texas State Tuberculosis Sanatorium, 

Carlsbad, Texas 



ST. LOUIS 

C. V. MOSBY COMPANY 
1921 



TfC3i\ 

•Gra 



Copyright, 1921, By C. V. Mosby Company 
(All Rights Reserved) 



Press of 
C. V. Mosby Company 
St. Louis, U. S. A. 



FEB 18 1921 

©CLA605806 



PEEFACE 

It lias been impossible for me to give the credit 
in this small volume, to all my past associates in 
tuberculosis work for their many suggestions and 
much good advice, without which suggestions and 
advice the writing of this small book would have 
been impossible. 

I have received much benefit from the following 
books, coupled with the advice and suggestions of 
my teachers and associates, and I wish to pay my 
respects here to the authors and editors of the 
following books and journals : 

Hawes: Early Pulmonary Tuberculosis. S 

Bkowjst : Eules for Eecovery from Tuberculosis. 

Corbett : The Causes of Tuberculosis. 

Pottenger: Clinical Tuberculosis. 

Boishstey: Pulmonary Tuberculosis and Its Com- 
plications. 

Clapp: Auscultation and Percussion. 

Knopf : Tuberculosis as a Disease of the Masses 
and How to Combat It. 

The American Eeview of Tuberculosis. 

The Journal of the Outdoor Life. 

My thanks are due E. E. Luhn, Jr., for assisting 
in preparing the manuscript of this book. 



CONTENTS 

CHAPTER PAGE 

I. History of Tuberculosis 13 

II. Predispositions to Tuberculosis 16 

III. The Cause of Tuberculosis 19 

IV. Diagnosis of Tuberculosis 23 

V. Physical Signs 33 

VI. Classification of Tuberculosis 42 

VII. Pathology of Tuberculosis 46 

VIII. Physiology of Tuberculosis 53 

IX. Treatment of Tuberculosis 64 

X. Treatment of Complications in Tuberculosis . 79 

XL Exercise and Rest in Tuberculosis 87 

XII. Climate in Tuberculosis 92 

XIII. Artificial Pneumothorax in Tuberculosis . . 96 

XIV. Tuberculin Therapy 104 

XV. Vaccines in Tuberculosis 108 

XVI. The Use of X-ray in Tuberculosis 109 

XVII. Details in the Daily Treatment 114 

XVIII. Differential Diagnosis in Tuberculosis . . . 118 

XIX. Prognosis in Tuberculosis 121 

XX. Resistance in Tuberculosis , . . . 126 

XXI. Prevention of Tuberculosis 132 

XXII. The Role of the General Practitioner in Tu- 
berculosis 136 

XXIII. The Control of Tuberculosis 139 

XXIV. History Taking 143 

XXV. Staining the Tubercle Bacilli 145 

XXVI. Don'ts for the Physician 146 

XXVII. Marriage in Tuberculosis 147 

XXVIII. Summary 151 

7 



ILLUSTRATIONS 

FIG. PAGE 

1. Bungalow for tuberculosis patients 32*^ 

2. Temperature curve in incipient cases 39' 

3. Temperature curve in case with acute flare-up .... 40" 

4. Artificial pneumothorax apparatus 66 

5. Daily record chart 77'"' 

6. Temperature curve in a case of tuberculosis pneumonia, 

treated with artificial pneumothorax 101 " 

7. Drop in temperature in a case treated with pneumothorax 102 

8. X-ray picture of pulmonary tuberculosis, right upper half 

with consolidation and cavity 112* 

9. X-ray picture of pulmonary tuberculosis of right apex . 112 

10. X-ray picture miliary tuberculosis 112 

11. X-ray picture advanced pulmonary tuberculosis .... 112 



INTRODUCTION 

There are today many books to be had dealing 
with the subject of tuberculosis. The majority of 
these books are very lengthy and deal with the 
many theories of tuberculosis ; and while they are 
indispensable to the specialist and research worker, 
still they do not appeal to the general practitioner, 
who is looking for information that will be of prac- 
tical value in his cases in question, especially from 
the standpoint of diagnosis and treatment. 

The author fully realizes the great part to be 
played by the general practitioner in the Antituber- 
culosis Campaign, and also realizes that many of 
these practitioners have not had adequate training 
in the branches of tuberculosis as understood to- 
day. 

Numerous papers on the different phases of tu- 
berculosis have been published in nearly all the 
medical journals; however, these articles are 
widely scattered and very easily mislaid. 

There are a few small books on the subject of 
tuberculosis, which are more practical for the 
general physician than are the larger works, but 
there seems to be room for one more such book. It 
is the hope of the author that the practical con- 
siderations in the different chapters of this small 
book will tend to help the general physician to be 
more on the lookout for the practical than the theo- 
retical when considering his tuberculosis patients. 

J. B. McKnight. 
11 



PRACTICAL TUBERCULOSIS 



CHAPTER I 



HISTOEY OF TUBERCULOSIS 

In the early medical writings, before the Chris- 
tian era, there is on record a great deal about the 
consumptive : the person with the wasted body; the 
cougher and spitter. 

For many years " consumption " was the name 
given to the conditions where there was a consum- 
ing of the body. It was known that consumption 
was not found in the savage, but in those who 
lived a community life. 

Observers in those times found that those who 
presented these symptoms of consumption died. 
The disease was thought to be inherited, since it 
appeared in generation after generation in the 
same family. It was also known to be a disease of 
early adult life. 

At this time nothing was known of the cause or 
effect of the disease in the body; physicians made 
their diagnosis from the symptoms, which were 
those of the last stages of the disease. On account 
of their previous teachings, many physicians of to- 
day follow the example of earlier observers, with 

13 



14 Practical Tuberculosis 

the result that they do not diagnose their cases un- 
til they are advanced and hopeless. 

The practice of postmortem examinations came 
into vogue something over a hundred years ago, 
and among these cases examined postmortem were 
many consumptives, with the result that the bodies 
of these consumptives were found to contain, es- 
pecially in the lungs, small grayish or yellowish 
cheesy structures. These small areas were called 
" tubercles. ' ' 

It was shown that consumption was caused by 
the growth and development of these tubercles, 
though there was no strict definition of the condi- 
tion known as consumption, nor of the condition 
wherein a few scattered tubercles were found, 
which today is known as "incipient tuberculosis." 
Physicians were only able to diagnose the disease 
by symptoms which today are recognized as those 
of advanced tuberculosis or consumption. 

Very few physicians listened to the chest. Laen- 
nec, however, developed the arts of auscultation 
and percussion and compared the findings with 
pathologic conditions found at autopsy. 

By animal experimentation Villemin produced 
tuberculosis in the animals infected with tubercles 
from the consumptive's lungs. Others confirmed 
the results of his experiments. 

In 1882, Eobert Koch isolated a bacillus which he 
named the ' ' tubercle bacillus, ' ' and proved it to be 
the cause of tuberculosis. 



History 15 

Since that time many remedies have been given 
in an effort to cnre tuberculosis, without any direct 
results. Prevention of tuberculosis by education 
is the object of antituberculosis workers today, as 
is also early diagnosis, and the institution of treat- 
ment at the earliest possible moment. 



CHAPTER II 

PREDISPOSITIONS TO TUBERCULOSIS 

For many years we have been taught that the 
predisposing causes of tuberculosis such as lack of 
nourishment, impure air, excesses of all kinds, as 
well as certain diseases, such as typhoid fever and 
scarlet fever, made one susceptible to tuberculosis. 

In view of recent researches along the lines of im- 
munity, it is evident that some of our ideas regard- 
ing the predisposing causes of tuberculosis were, to 
a great extent, erroneous. The fact that so many 
people today show that they have had an infection 
or disease makes one feel that the tubercle bacillus 
is harbored by the entire human race, and that the 
predisposing causes do not predispose to infection, 
but determine to a certain extent the amount and 
severity of the disease. 

We are aware that the tubercle bacilli which are 
scattered on the virgin soil produce greater destruc- 
tion than do those which fall where others have 
fallen. We recall Webb's experiment where he 
found it possible to inject as many as 150,000 living 
tubercle bacilli into a guinea-pig at one time, fol- 
lowing previous graduated injections, without pro- 
ducing disease, whereas ordinarily so small a num- 
ber as twenty bacilli would cause disease and death 
in the guinea-pig. 

16 



Predispositions 17 

We can also recall the number of cases of tu- 
berculosis that follow colds of different severity, 
including genuine influenza. We cannot in a prac- 
tical way particularize on predisposing causes of 
tuberculosis, since we do not know at the present 
time whether these causes work directly or indi- 
rectly, whether the predisposition is a result of me- 
chanical changes in cells and tissues or whether it 
is due to an increased expenditure of energy. It 
is very probable that any agent or condition which 
affects the cells of the body individually or collec- 
tively interferes with their power of resisting in- 
vading microorganisms and their toxins. 

Eealizing the difference in the reactivity of dif- 
ferent individuals, their different habits and inher- 
itances, and also realizing the difference in viru- 
lence of different strains of tubercle bacilli, we real- 
lize the impossibility of standardizing any predis- 
position to tuberculosis ; and it is evident, further- 
more, that what would be predisposing causes for 
one would not be predisposing causes for another. 

A life lived according to the demand of nature, 
as taught by physiologic laws, would prevent, to a 
great extent, these predisposing causes, relative as 
they are, and the opposite would also be true. 

For many years the physician and the layman 
thought one had to be "run down" in order to con- 
tract tuberculosis. Without a doubt, this run-down 
condition is a result of the infection by the tubercle 
bacilli and not a cause of the infection. 



18 Practical Tuberculosis 

There is no doubt that any person will develop 
tuberculosis if he will inhale, ingest or pick up in 
any other way a sufficient number of virulent bacilli 
at one time. 

The evidence of acute infection in persons with 
lowered resistance, due to fatigue or getting the 
body chilled unduly, makes one feel that the same 
condition would predispose to tuberculosis, and 
that the question of one's resistance may often be 
answered by a consideration of one's energy. 



CHAPTER III 

THE CAUSE OF TUBERCULOSIS 

In 1882, Robert Koch discovered the tubercle 
bacillus and proved it to be the cause of tuberculo- 
sis. While it is evident that Villemin, Conheim and 
others were working along the same theoretical 
lines regarding the cause of tuberculosis, still Koch 
developed the technic for demonstrating the bacilli. 

There are three generally recognized types of tu- 
bercle bacilli : human, avian and bovine. The bio- 
logic activities of each are slightly different as well 
as the morphologic appearance. The human and 
the bovine are more alike than the avian and bovine 
or the avian and human. 

The tubercle bacillus is about one ten-thousandths 
of an inch in length and one hundred-thousandths 
of an inch in width. It is rod shaped and mul- 
tiplies by fission ; it is nonmotile and very resistant 
to the ordinary stains. This power of resistance to 
stains is claimed to be due to a waxy substance in 
the bacillus. 

At times the tubercle bacillus presents a beaded 
appearance, and some authors think that this type 
is found in very sick patients. Often, the bacilli 
present a branched appearance and are sometimes 
confused with the streptothrix. 

19 



20 Practical Tuberculosis 

In staining the tubercle bacillus the Ziehl-Neil- 
sen stain is the one most frequently used, although 
in sputum work, Gabbett's stain has been used to a 
good advantage. Urine sediments can be examined 
after being stained and treated with both acid and 
alcohol in order to rule out the smegma bacillus 
which resembles the tubercle bacillus. 
* The virulence or disease-producing properties of 
one strain of bacilli is different from another, as is 
also the length of ]if e. Cornet found that tubercle 
bacilli, found in a room which had been inhabited 
by a consumptive six years previously, were still 
virulent. Krause has shown that bacilli live for a 
long time in caseous lungs which have been buried 
in the ground. Virulent bacilli have been found in 
the old calcified lesions of a tuberculous person. 

It has been estimated that an advanced consump- 
tive expectorates millions of tubercle bacilli in 
twenty-four hours. This is ample reason for hav- 
ing the tuberculosis patients cover their mouths 
when they cough and expectorate into covered 
sputum cups that are kept away from flies. 

It has been estimated that direct sunlight kills 
tubercle bacilli in from one-half to two hours and 
that indirect sunlight takes a little longer. The ef- 
fect of cold is only to retard the growth of the 
tubercle bacillus and not to kill it. The growth of 
the tubercle bacillus is naturally slower than that of 
most germs and requires special media for its 
growth. 



The Cause 21 

Many general practitioners consider that tuber- 
cle bacillus must be present in the sputum before 
pronouncing a case tuberculous. This idea is a fatal 
one for many patients of these physicians. When 
it is possible to demonstrate bacilli in the sputum, 
the disease is, as a rule, quite far advanced. Many 
physicians have felt certain from the history of 
their case that it was tuberculosis, but not finding 
the tubercle bacillus, have waited until when it was 
eventually demonstrated the patient was in the ad- 
vanced stage with little hope for improvement from 
treatment. 

In order for tuberculosis to be transmitted from 
person to person there must be some continuous 
cycle of the bacillus transmission from person to 
person or from animal to animal or from animal to 
person. The tubercle bacillus can only live in ani- 
mal tissues. Being nonmotile it requires a carrier. 
In the case of the young baby, this may be the milk 
of tuberculous cattle, when it is not pasteurized, or 
contaminated articles placed into the baby's mouth. 
In the older person there are many other ways in 
which the bacillus may be carried from one person 
to another : by hand-shaking or touching anything 
that a careless consumptive has touched, or by in- 
haling the spray from a tuberculosis patient's 
mouth while coughing. Flies are also great car- 
riers of the disease. 

It is not definitely known just how the tubercle 
bacillus enters the system. It is very probable 



22 Practical Tuberculosis 

that infection results from many different methods 
of entrance of the bacillus into the body. Many 
authors assert that the inhalation method is the 
most frequent, and others, the ingestion method, 
and still others, that the bacillus first enters into 
the lymphatic structures of the upper respiratory 
tract. 

We should, by every possible means, overcome 
all chances of occurrence of infection by isolation of 
the careless and incorrigible consumptive, and by 
sterilization of all foods which come from question- 
able sources. 

Tubercle bacilli have been found in practically 
every place where a careless tuberculosis patient 
has stayed and also in eating utensils, towels, bed 
clothing and articles contaminated by such a pa- 
tient. 

Feces of tuberculosis patients contain many bac- 
illi which have not lost their virulence during their 
passage through the acid of the stomach and the 
rest of the alimentary tract. 

Tubercle bacilli are killed by boiling, by different 
germicidal agents and by sunlight. They thrive in 
dark, dirty corners. It is the custom of people to 
expectorate in dark, dirty corners, thereby facili- 
tating the growth of the bacilli. Hogs frequently 
contract tuberculosis from cattle by being fed on 
the milk of tuberculous cattle and also from eating 
substances contaminated by the feces of the tuber- 
culous cattle. 



CHAPTER IV 

DIAGNOSIS OF TUBERCULOSIS 

Most of the literature of today dealing with tu- 
berculosis emphasizes the importance of early diag- 
nosis. We should not necessarily try to diagnose 
early tuberculosis but we should try to find active 
tuberculosis. 

Physicians, who have examined many patients, 
remark that it is impossible to find the adult person 
with absolutely normal sounding lungs. There are 
adventitious sounds, or abnormal breath, or voice 
sounds in every case that a physician examines if 
he will but put the necessary time into the examina- 
tion. That many of these signs are due to the ac- 
tivities of the tubercle bacillus is very probable; 
hence, if one is to treat all cases with abnormal 
chest signs, one will be treating the entire adult 
population. 

It is impossible to standardize things tuberculous 
so that one can hit every case, but for all practical 
purposes one can make a diagnosis of activity if 
provided with a summary of the case, and if com- 
mon sense is exercised. Too often the physician 
depends on the chest signs alone in diagnosing ac- 
tivity when he should have had the temperature, 
pulse and weight charts, as well as the history and 

23 



24 Practical Tuberculosis 

laboratory findings, to help to decide the stage of 
the disease. 

In diagnosing activity, the toxic symptoms are 
the most important from a practical standpoint. 
The^tirgd-i eeling is the first symptom complained 
of, as a rule; then nervousness, lack of endurance, 
loss of appetite, loss of weight and strength, and 
night sweats. Fever and anemia are also fre- 
quently noted. The rapid pulse and the elevated 
temperature are very frequent symptoms of activ- 
ity, and it is necessary for the temperature and 
pulse to be taken, especially during the afternoon, 
because the patient often exhibits fever at certain 
times of the day and during the remainder of the 
day the temperature is normal. 

Cough, hoarseness, pain in the chest and circula- 
tory disturbances are further symptoms; but it 
must be remembered that it is possible to have 
tuberculosis and never cough; in fact it must be 
remembered that very few tuberculosis patients 
exhibit all the signs of tuberculosis even during 
their entire illness. 

Expectoration of blood and sputum are further 
symptoms of tuberculosis, and often the spitting of 
blood is the symptom that brings the patient to see 
the physician. Too often, in the past, the physician 
has told the patient that the blood was from the 
throat or bronchial tubes, and the patient has been 
only too glad to believe this statement, with the re- 
sult that when he learns the truth about his con- 



Diagnosis 25 

dition he loses all regard for the physician's ability. 
Many tuberculosis patients give expectoration of 
sputum as the first symptom noticed, and this 
symptom has all too often been blamed on bronchi- 
tis or asthma or some other respiratory affection. 

Cessation of menstruation is often a result of tu- 
berculosis, as are also irregularities in menstrua- 
tion, anemia and chlorosis. 

Pain in the chest, or in fact any abnormal sensa- 
tion in the chest, should be considered possibly due 
to tuberculosis. Physicians seem to have the idea 
that sharp knife pains must be present before they 
can say a patient has pleurisy. Patients, when 
asked if they have pleurisy, will a great many times 
say no. Further questioning regarding pain 
brings the answer that they have had pain in the 
chest for a long time. When the physician ques- 
tions a patient about pleurisy, he must explain that 
any abnormal pain or burning feeling in the chest 
may be due to pleurisy. 

Abnormalities in the appearance of the chest, 
hectic flushing of the cheeks, and clubbed fingers are 
often found, but more often in the advanced cases ; 
hence, the physician should not rely on these symp- 
toms in determining the presence of early disease. 

In considering observation we can often get in- 
formation as to the presence of complications. The 
barrel-shaped chest is found in emphysema; asth- 
matics present the stooped attitude; pleural effu- 
sions cause distention and immobilization to a cer- 



26 Practical Tuberculosis 

tain extent; as does also a spontaneous pneumo- 
thorax, the differentiating point being that in spon- 
taneous pneumothorax there is a tympanitic note 
on percussion whereas in pleural effusion the note 
is flat ; also in spontaneous pneumothorax there is a 
distention of all intercostal spaces if the rupture is 
complete. 

Palpation and percussion are both of practical 
value in making a diagnosis, since the physician's 
sense of touch is often better trained than his sense 
of hearing. It is best to percuss the patient's chest 
while in different positions, because one can often 
differentiate between a movable effusion and a con- 
solidation by this method and in no other way, ex- 
cept by the x-ray. 

The examiner must be comfortable and relaxed 
and have the patient in the right frame of mind. 
Furthermore, he must not be in a hurry when he is 
attempting to make a diagnosis on a suspected tu- 
berculosis patient, and his mind must be free and 
concentrated on the case. Having the patient 
stripped to the waist is very necessary. It is best 
for the physician to develop a certain routine of 
examination and to follow this without omissions. 

Some physicians take the history first, but I pre- 
fer to examine first and then take the history, since 
one is apt to be biased by what the patient says, and 
furthermore, it stimulates a physician to find what 
there is in the chest, thus having his own mental 
picture of the diseased process. This is especially 



Diagnosis 27 

true if he has to compare his findings with those of 
another expert. 

My method of procedure is first, while the patient 
is standing up with chest bared, to observe the 
chest while at rest and also during expiration and 
inspiration. I compare the two sides and make 
notes of any differences in the anatomy or physiol- 
ogy as well as in the general tone, and in the condi- 
tion of the skin. 

Following the observation, the chest is palpated, 
taking notice of the resistance of the tissues, and 
also the sound-conducting properties, Next the 
chest is percussed with both hard and soft strokes 
and notice is taken of any disparity in the two 
sides or in the different areas in the same side. 
Auscultation comes next, first during normal 
breathing to observe any modified breath sounds 
and to time the appearance of the adventitious 
sounds, then with deeper breathing to bring out the 
sounds missed before. Following the deeper 
breathing the patient is made to expel the air from 
the lungs and then cough twice gently while the 
lungs are empty, with the mouth covered with a tis- 
sue to prevent spraying the room with bacilli. It 
is remarkable how this cough following expiration 
brings out the latent rales. If physicians would 
only use this method they would often find more in- 
volvement than is found with ordinary breathing. 
During auscultation the chest is gone over syste- 
matically, starting at the right apex covering the 



28 Practical Tuberculosis 

front of the right lung, then the front of the left 
from apex to base, and then the back in the same 
way, comparing if necessary different locations. A 
hairy chest is a great obstacle in examination, and 
this should be shaved or the hairs should be moist- 
ened with soap and water. 

After completing the chest examination the ears, 
nose, throat and glands of the neck are examined. 
Finally, the history is taken, after having charted 
down the physical findings. Students of tubercu- 
losis should make their own examinations, chart 
them, and then compare them with those of their in- 
structor. A study of the normal chest is, of course, 
necessary before a study of the abnormal is made ; 
the student will find that all vesicular breathing is 
not the same in force, but may be similar in char- 
acter. 

It is often necessary to observe a case of some 
length of time before a correct diagnosis can be 
made, especially in cases with complications which 
would cause adventitious sounds of their own ac- 
cord, and also in cases in which one knows that 
there are abnormal signs in the chest, but is not 
positive that these signs are due to active tubercu- 
losis. In these doubtful cases the patient should be 
given the benefit of the doubt ; the physician should 
try to prove that the condition is not tuberculous, 
instead of trying to prove that it is tuberculous 
and instituting treatment while making proof. 

The physician in the future must rely on the sub- 



Diagnosis 29 

jective symptoms in the diagnosis of active tuber- 
culosis ; by this the author does not mean only the 
general practitioner, but also the specialist. The 
teachers of tuberculosis in the past have been, to 
a certain extent, the cause of the delay in diagnosis 
in tuberculosis, for the reason that they have had 
their students listening for crepitant rales and pay- 
ing too much attention to the chest without enough 
attention to the toxic symptoms. Tuberculosis 
specialists today can tell much more about the ac- 
tivity of a case by considering these symptoms 
than by prolonged examinations with the stetho- 
scope. 

It must be remembered that the case that has 
the least amount of trouble in the chest may be in 
a worse condition than the one with advanced lung 
signs. This, of course, is because the advanced 
case has, during his long time of disease, walled off 
his foci and also developed his antitoxin. Dr. Allen 
K. Krause has told us that a tuberculosis patient's 
death is due to an accident, hence, there are good 
reasons for considering the advanced case more 
optimistically than has been our custom heretofore. 
A little exercise in the incipient case has innumer- 
able times been the cause of the accident result- 
ing in death. The wall of defense around the 
focus of infection has not been strong enough, and, 
as a result of exercise, this wall had broken down, 
allowing the bacilli to escape, with the eventual 
production of a caseous pneumonia, miliary tu- 



30 Practical Tuberculosis 

berculosis, or some other acute tuberculous infec- 
tion, and death. 

Persistence is the keynote of the subjective 
symptoms. The physician must be suspicious of 
tuberculosis in all his cases and look for the tired 
feeling, pain in the chest, cough or weak voice, spit- 
ting of blood, slight loss of appetite, weight and 
strength, nervous instability, lack of muscle tone, 
indigestion, elevated temperature and pulse at 
some time during the day, especially in the after- 
noon. 

The x-ray is a valuable help in diagnosis, but 
must be used by one who is trained in lung exami- 
nations and plate reading. Very few men can read 
an x-ray plate properly. Tuberculin is an agent 
that has been used for diagnosis too often, if any- 
thing, as it probably has activated many inactive 
foci, with consequent death in a number of in- 
stances. Eegarding tuberculin, Dr. Knopf says: 
"No tuberculin test should be resorted to if subjec- 
tive and objective signs and symptoms or sputum 
examinations have been sufficient to demonstrate an 
active tuberculosis ; and the one who wishes to re- 
sort to the tuberculin test should first familiarize 
himself with the relative value of the tests now 
used and the precautions which should be exercised 
to avoid the errors or complications which might 
arise through injudicious use. ' ' 

The practical value of the skin test is question- 
able in adults. This test being a test for anti- 



Diagnosis 31 

bodies naturally would not prove when the infec- 
tion causing the antibodies took place, and our 
present knowledge of tuberculosis shows that in 
some cases 50 per cent of the children at the age 
of six years react to the skin test. Dr. Bartlett 
found this to be the case in the von Pirquet Survey 
in Framingham, Mass. 

I have frequently found that patients with spu- 
tum bacteriologically positive for tubercle bacilli, 
with apparently good resistance and with signs of 
far advanced disease although not apparently 
active, would not give a positive skin test. 

The complement-fixation test is of some value, 
but only in conjunction with other signs and symp- 
toms. Dr. Lawrason Brown and Mr. Petroff have 
shown that guinea-pigs give a positive complement 
fixation three days after infection experimentally, 
but it is not known what length of time must elapse 
in order to obtain a positive complement fixation 
in the human body, after infection. It is to be 
hoped that future experimentation by these men 
and others will remove the present difficulties from 
this standpoint. 

The diagnosis of tuberculosis in very young 
children is very difficult so far as stethoscopy is 
concerned and so far as the toxic symptoms are 
concerned. A history of contact is a great help. 
Skin tests and x-ray examinations are valuable. 
Presence of enlarged glands, which cannot be at- 
tributed to other conditions and which persist, are 



32 Practical Tuberculosis 

valuable aids in the diagnosis. Sweating of the 
head, continual bad disposition, fever, rapid pulse, 
deranged stomach, and poor general appearance 
are frequent symptoms of tuberculosis in the very 
young. 

It is very difficult to get sputum for examination 
from the very young ; but my experience with my 
own baby who died at the age of ten months with 
tuberculosis after a three months' sickness, proves 
that one should examine the stools of these very 
small children for the bacilli of tuberculosis, being 
careful to differentiate, of course, from other acid- 
fast bacilli. 



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CHAPTER V 

PHYSICAL SIGNS 

It is impossible to tell by the physical signs alone 
how recent an abnormal condition in the lungs may 
be or how long such a condition has existed. If it 
were possible to examine every person at stated 
intervals, physicians, no donbt, would be able to 
compare physical signs from time to time and add 
to the present knowledge of these signs. 

One can, however, tell by physical signs the ex- 
tent of involvement, and this, coupled with a study 
of the other symptoms : history, x-ray examinations 
and laboratory reports, is a great help in the sum- 
mary of the case. 

Often the case with the largest amount of in- 
volvement and, from a standpoint of physical signs 
the one with apparently the most activity, is the 
one that offers the best prospects of recovery, when 
all other factors in the case are considered. 

In order for the general practitioner or the 
student of tuberculosis to appreciate intelligently 
the physical signs in tuberculosis, it is necessary 
for him to understand the anatomy and physiology 
of the lungs. It is not necessary thoroughly to 
understand the minute anatomy in anything except 
the structural unit of the lungs, but the knowledge 

33 



34 Practical Tuberculosis 

of the general makeup of the lungs is essential in 
order to understand the production of abnormal- 
ities in breathing and adventitious sounds. 

It is necessary for the physician to have a clear 
mental picture of the extent of the lungs in the 
chest, their general shape and appearance, as well 
as their relation with other structures nearby. 

In order to understand the abnormal physical 
signs, it is necessary first to study the normal chest. 
When we stop to consider the different breath 
sounds in the normal lungs, we are impressed with 
the difference in character of these sounds. This 
is probably one reason why it is so difficult for the 
beginner to learn the normal; that is, there is no 
absolute normal and the line of demarcation be- 
tween the normal and abnormal is often very much 
blurred. Age, occupation and the place of resi- 
dence, as well as habits and inheritances, all enter 
into the anatomic shaping of the respiratory tract; 
consequently we have a difference even in the nor- 
mal physical signs which the specialist often finds 
difficult of classification. 

Concentration of the attention of the examiner 
on what he is doing is one of the necessary helps 
in eliciting the chest sounds, and he must be able 
to hear and have a stethoscope that is comfortable 
to the ears and auditory canal. Many general prac- 
titioners are experts on chest examinations, al- 
though they cannot explain always the pathologic 
conditions producing these abnormal signs. 



Physical Signs 35 

Physicians have often told me that it was impos- 
sible for them to study tuberculosis on account of 
lack of material. It is not the number of cases 
examined and treated that makes the tuberculosis 
specialist ; but it is the amount of time spent on a 
few cases, and the amount of study and interest 
in each case, that qualify the examiner eventually 
to be a specialist. So far as lack of material is 
concerned, it is very evident that a physician would 
have a very poor practice, who did not have at least 
twenty tuberculosis patients under his supervision 
each year, although in most cases these patients are 
treated for other diseases. 

The physician, undertaking a study for the prac- 
tical signs, must acquaint himself with some of the 
physical qualities of sound. It is necessary to as- 
certain the pitch, quality, rhythm, intensity and 
duration of the inspiratory and expiratory sounds 
in the normal in order best to compare them with 
the abnormal. In some cases with slight involve- 
ment, it is most difficult to differentiate the normal 
from the abnormal on account of mechanical or 
other conditions which change the anatomic make- 
up of the lungs. The intensity of all sounds is in- 
creased or diminished according to the rapidity and 
force of the respiratory acts. The normal vesic- 
ular respiration is on inspiration a soft diffused 
sound of a breezy character, gradually developed 
and continuous, and of low pitch. The expiratory 
sound in vesicular breathing is not vesicular but 



36 Practical Tuberculosis 

feebly blowing in quality, with lower pitch and less 
intensity than that in inspiration. The expiration 
is usually not more than one-fourth the length of 
inspiration, being absent in many cases. 

Puerile and senile respirations have the same 
physical qualities as vesicular respiration, except 
that in the puerile type the intensity is increased 
and in the senile, diminished. These respirations 
are found in all parts of the chest, but may vary 
in intensity even in the same lung, due to increased 
activity of certain vesicles. 

In tracheal and laryngeal respiration, the inspi- 
ration is tubular, loud, dry and hollow. The ex- 
piration is tubular, more intense than inspiration, 
and of little longer duration. 

In diseased conditions there are the respirations 
of abnormal intensity : exaggerated respiration 
when there is an increased intensity, feeble respi- 
ration with diminished intensity, and suppressed 
respiration when there is no sound heard. 

Further, there are those respirations of abnor- 
mal rhythm, such as jerking inspiration and pro- 
longed expiration, and lastly, those respirations 
with abnormal quality and pitch, such as bronchial 
respiration and bronchovesicular respiration. In 
bronchial respirations the inspiration is tubular, 
nonvesicular and shortened. The expiration is 
tubular, prolonged, of a higher pitch and more in- 
tense than the inspiration. In bronchovesicular or 
the rude, rough or harsh respiration, the inspira- 



Physical Signs 37 

tion has a combined tubular and vesicular quality 
in different proportions. The expiration is pro- 
longed, more intense, of a higher pitch than inspira- 
tion. In cavernous respiration there is a blowing 
inspiration and expiration produced by the passage 
of air into and out of a cavity with flaccid walls. 
In the amphoric respiration the sounds are similar 
to that produced by blowing across the mouth of 
a large bottle ; this respiration is found in cavities 
with rigid walls. The conditions causing these ab- 
normal signs are many, and although these signs in 
the chest are not absolute proof of tuberculosis, 
they must, of course, be used in conjunction with 
the other manifestations in the case. 

Adventitious Sounds (Rales or Rhonchi) 

In order to produce rales there must be some 
foreign substance or abnormal condition of the res- 
piratory tract to act as a partial obstruction to the 
entrance and egress of air in the tubes and lung 
vesicles. There are the dry and moist laryngeal 
rales, the former of which are wheezing or whis- 
tling in character, and the latter bubbling ; also the 
bronchial rales, sonorous and sibilant, the former 
being of low pitch and the latter of high pitch and 
produced in the large and small tubes, respectively. 
There are, furthermore, the coarse mucous, fine 
mucous and subcrepitant rales which differ in char- 
acter of sound in degree only. The Army Medical 



38 Practical Tuberculosis 

School uses the term indeterminate" to cover the 
latter rales. The crepitant rales, which are of a 
fine, dry, crackling character and heard exclusively 
near the end of inspiration, are produced in the 
vesicles and are the symptoms of a circumscribed 
pneumonic process. The author has found that 
these rales persist for a long time ; hence, they may 
not necessarily be considered a result of a very 
acute process in all cases. Cavernous rales are of 
a hollow, gurgling sound of varying intensity. 

Pleural inflammations give many different 
sounds, according to the pathologic condition pres- 
ent, varying from the fine, crackling rales on in- 
spiration to the rough, squeaking sound of dry 
pleura during respiratory movements. In nearly 
all adults one will find fine crackles in the lower 
axillary region on deep inspiration ; naturally, one 
should be suspicious of tuberculosis in these cases, 
although the moisture is probably caused by an in- 
flammation due to pressure. I have found this con- 
dition especially in shoe workers who have had the 
shoe or some part of the shoe machine pressed 
against the chest while stooped over their work, 
the lung thus not being allowed to work properly. 

The healthy voice transmission is variable and 
depends upon the physical character of the area 
auscultated. Sound is not conducted through the 
fat chest as well as through one with less adipose 
tissue. The diseased voice transmission is very 
variable. There are diminished vocal resonance 



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Classification 41 

in any condition where the circulation of air in the 
tubes and vesicles is prevented, and increased vocal 
resonance resulting from an increased sound re- 
flecting power in the tubes, as in consolidation in 
some cases. In bronchophony, where the voice 
sounds seem near the ear a greater solidification 
than in the above condition obtains. The caver- 
nous and amphoric whispers have the same char- 
acter of sound as the expiratory sound in the re- 
spective respirations and are produced by the same 
causes. In pectoriloquy there is a direct transmis- 
sion of sounds to the ear. The condensed lung 
tissue and cavity formations, resulting in sound 
reflecting walls, produce this sign. 

The common percussion signs in the chest are 
the normal or vesicular resonance, the abnormal or 
flat and dull resonance, tympanitic or exaggerated, 
and amphoric. Actual experience in eliciting these 
resonances is essential. 

Dullness or flatness usually indicates solidifica- 
tion or fluid, and tympany indicates air in the 
pleural cavity (spontaneous pneumothorax), while 
exaggerated resonance is usually an indication of 
emphysema. 



CHAPTER VI 

CLASSIFICATION OF TUBERCULOSIS 

It is evident that any attempt to classify tuber- 
culosis will be fraught with many difficulties when 
its relativeness is taken into consideration. As 
has been previously mentioned, an incipient case 
may be in a worse condition than some of the ad- 
vanced cases, and, furthermore, the extent of lung 
involvement per se does not give one suitable in- 
formation on which to base a diagnosis or treat- 
ment. Many times a case that would fall under the 
incipient classification has existed longer than one 
that would be considered far advanced, due to the 
differences in treatments, habits and all other fac- 
tors influencing the resistance of the cases in ques- 
tion, and also to the variation in virulence of dif- 
ferent tubercle bacilli. There are many borderline 
cases in which the classification depends upon the 
personal ideas of the examiner. It is very neces- 
sary, however, to classify tuberculosis after some 
accepted method of classification, not only from a 
statistical point of interest, but also so that the* 
superintendents of the different institutions may 
determine the suitability of certain cases for ad- 
mission to their different sanatoria, according to 

42 



Classification 



43 



the requirements of these sanatoria for admission. 
The National Tuberculosis Association has issued 
a very helpful and interesting booklet for those 
doing tuberculosis work, which gives the different 
definitions of terms used for defining the stages 
and symptoms of the different stages, as well as 
other practical information. 

The following classification is the one adopted by 
the National Tuberculosis Association as the result 
of the work by Dr. Eathburn. This classification 
admits of different combinations of each stage, 
such as incipient, a, b, c, etc., and gives a more 
explicit definition of the disease from the stand- 
point of resistance of the patient or virulence of 
the infection than did the previous classifications. 



ON ADMISSION 



Lesions 



Incipient. Slight infiltration 
limited to the apex of one or 
both lungs, or to a small part 
of one lobe. No tuberculous 
complications. 

Moderately advanced. Marked 
infiltration more extensive than 
in incipient, with little or no 
evidence of , cavity formation. 
No serious tuberculous compli- 
cations. 

Far advanced. Extensive lo- 
calized infiltration or consoli- 
dation in one or more lobes, or 
disseminated areas of cavity 
formation, or serious tubercu- 
lous complications. 



Symptoms 



A. (Slight or None.) Slight 
or no constitutional symptoms 
including particularly gastric 
or intestinal disturbances, or 
rapid loss of weight; slight or 
no elevation of temperature or 
acceleration of pulse at any 
time during the twenty-four 
hours. Expectoration usually 
small in amount or absent. 
Tubercle bacilli may be present 
or absent. 

B. (Moderate.) No marked 
impairment of function, either 
local or constitutional. 

C. (Severe.) Marked impair- 
ment of function, local and con- 
stitutional. 



44 Practical Tuberculosis 

This schema offers the following combinations: 
Incipient A, B and C. Moderately Advanced, A, 
B and C. Far Advanced A, B, and C. 

DISCHARGED 

A. Apparently cured. All constitutional symptoms and expec- 
toration with bacilli absent for a period of two years under ordi- 
nary conditions of life. 

B. Arrested. All constitutionl symptoms and expectoration with 
bacilli absent for a period of six months; the physical signs to be 
those of a healed lesion. 

C. Apparently arrested. All constitutional symptoms and expec- 
toration with bacilli absent for a period of three months; the 
physical signs to be those of a healed lesion. 

D. Quiescent. Absence of all constitutional symptoms; expec- 
toration and bacilli may or may not be present; physical signs 
stationary or retrogressive; the foregoing conditions to have ex- 
isted for at least two months. 

E. Improved. Constitutional symptoms lessened or entirely ab- 
sent; physical signs improved or unchanged; cough and expectora- 
tion with bacilli usually present. 

F. Unimproved. All essential symptoms and signs unabated or 
increased. 

G. Died. 

It is probable that cases are often considered 
apparently cured when they are getting absorption 
from their tuberculous focus, but on account of a 
developed immunity there is no manifestation at 
the site of the lesion or in constitutional symptoms, 
so far as can be determined clinically. 

Although it is rare to find a person with a single 
stage of the disease from the pathologic stand- 
point, still it is possible to classify a case according 
to Bathburn's classifications and at the same time 
consider the pathologic condition in the chest, such 
as inflammatory or ulcerative, with the sub- 



Classification 45 

divisions of fibroinflammatory or fibroulcerative. 
By stethoscopic examination, observation of the 
sputum and use of the x-ray, these pathologic types 
can be determined, and this is often of assistance 
from the standpoint of prognosis as well as in de- 
termining the stage of the disease and future treat- 
ment. 



CHAPTER VII 

PATHOLOGY OF TUBERCULOSIS 

The amount and character of the reaction of the 
tissues to the injury produced by the entrance into 
the tissues of the tubercle bacillus depends upon 
the virulence of the infecting agent, upon the num- 
ber of bacilli and the resistance of the infected 
patient, and upon whether the infection is primary 
or secondary to another infection of the same 
nature. 

There is probably no other disease which offers 
so many different phases of the disease process as 
does tuberculosis. While the formation of the tu- 
bercle producing its mechanical wall of defence, as 
shown by Dr. Allen K. Krause and Dr. Boyd Cor- 
nick, is the initial reaction, still we may have in the 
same lung or even in the same lobe as a result of 
extension of the disease by continuity or lymphatic 
extension, inflammation, caseation necrosis, lique- 
faction necrosis, fibrosis, calcification, and many 
other degenerations at the same time. 

The tubercle bacilli throwing off their tuberculin 
produce inflammation or caseation according to 
whether the body cells are able to neutralize the 
toxins to a greater or less extent by production of 
antitoxin. There are many factors that decide 

46 



Pathology 47 

whether the fixed and wandering cells will develop 
their wall of fibrosis and wall off the infection, or 
whether the bacilli will gain the ascendency. The 
main factor is the treatment that the patient re- 
ceives at this time. 

Tuberculin, entering the blood stream, as it does, 
and circulating through the system, causes anti- 
tuberculin formation in the different cells. Accord- 
ing to Ehrlich's theory the nature of this antitu- 
berculin is that they are thrown-off cell receptors 
that have been produced in excess of the number 
needed resulting from the reconstruction of the cell 
following the initial poisoning. 
i When the tubercle bacillus enters the system we 
have a surrounding of the invading organisms by 
the fixed cells, reinforced by the wandering cells, 
with resulting fibrosis and healing in cases with 
good resistance. If for any reason the resistance 
is poor, the mechanical wall of defence is broken 
down, with resulting caseation, spread of tuber- 
culin and tubercle bacilli. If all goes well even at 
this time, we may get a calcification of the necrosed 
area without surrounding fibrosis. 

The caseated area, so called on account of the 
resemblance of the caseous area to cheese, is a 
coagulated proteid, resulting from the action of the 
tuberculin on the cells. 

In cases of mixed infection microorganisms 
reach this area either through the bronchial tubes 
or blood stream and produce more rapid disinte- 



48 Practical Tuberculosis 

gration of the lung tissue; the purulent sputum 
results to a greater degree than with the straight 
tubercle bacilli infection. 

At the same time that the lung cells are under- 
going necrosis there is an absorption, to a greater 
or lesser extent, through an imperfect wall of de- 
fence, a certain amount of tuberculin, reaching the 
general circulation, causing the toxic manifesta- 
tions of the disease. 

There is without doubt not a cell or tissue in the 
body that escapes the action of tuberculin. The 
action on the brain cells and nerves is manifested 
by the increased activity and irritability of these 
cells and on the skin by change of color and feeling. 
Furthermore, the irritability of the heart, kidneys 
and skeletal muscles in these toxic conditions is to 
be noted. The special senses are affected; also 
the vasomotor centers producing circulatory dis- 
turbances. 

It is quite possible that by further observation 
some early sign or symptom of tuberculosis may be 
developed by considering the irritability of the 
nerve and muscle fibers. 

It has been rather well demonstrated that, as a 
rule, tuberculosis is primarily a disease of the bron- 
chial or other lymphatic glands, and that with these 
glands as a base for operation the bacilli proceed 
by lymphatic extension or eruption into a bronchus 
or vessel to other parts of the body. 



Classification 49 

Dr. Mary Lapham has shown the number of en- 
larged and infected bronchial glands by means of 
x-ray examination, although naturally it cannot be 
proved that all these enlargements are due to 
tuberculous infections. 

It has been shown by some authors that from 30 
to 90 per cent of all bodies of tuberculous people 
that have come to autopsy have had an intestinal 
lesion either primary or secondary to the pulmon- 
ary infection. Only a few cases of tuberculosis 
of the stomach are on record and the same is true 
of esophageal and nasal infections. It has been 
shown that from 10 to 20 per cent of all cases have 
a laryngeal infection of varying degrees of sever- 
ity. Tonsils have been found infected in a fairly 
large percentage of cases. 

Pleurisy is a very frequent complication, many 
times being accompanied by effusion. I have fre- 
quently found a pleurisy with effusion following a 
cold or exposure in cases with apparently healed 
lesions in the lungs and have frequently demon- 
strated bacilli in the effusion in these cases. 

Glandular and bone tuberculosis are not very 
frequent, occurring more frequently in children. I 
have remarked the almost total absence of these 
forms of tuberculosis in the Southwest and their 
frequency in the Northwest and East. I am sure 
that the reason for the absence of these cases in 
the Texas State Tuberculosis Sanatorium is due, 
to a certain extent, to the almost continual sun- 



50 Practical Tuberculosis 

shine, and probably also to some extent to the good 
judgment of the superintendent, Dr. McKnight, in 
admitting early uncomplicated cases. 

Tuberculosis in very young babies usually ad- 
vances rapidly and terminates in a general miliary 
tuberculosis with meningeal complications. The 
cellular resistance in the young is not as good as 
in adults, probably because there have been no pre- 
vious slight infections. 

Tuberculosis of the kidney is fairly frequent, and 
the experiences of Dr. John B. Hawes with this 
form of tuberculosis points to the fact that this 
complication is more frequent than was formerly 
thought — the case and prognosis more hopeful. 

Neuritis is a frequent complication of tuberculo- 
sis even in the early stages, and we must consider 
the possibility of all neuritis attacks as resulting 
from tuberculous infection. 

The blood picture in tuberculosis is variable ex- 
cept that there is usually slight leucocytosis and 
anemia due to the small amount of hemoglobin, 
while the coagulability of the blood is also variable. 
Many cases show albuminuria. 

Cavity formation in tuberculosis is at times very 
beneficial. Closed cases that are absorbing all the 
products of metabolism of the, tubercle bacillus will 
in some instances eventually rupture this infected 
area into a bronchus and, following this cavity for- 
mation, make good improvement. 



Classification 51 

Blow-ups in tuberculosis are considered due to 
extension of the bacilli through the lymphatics. 
This idea seems to be wrong to a certain extent, 
since it would be necessary for the bacilli to enter 
the general circulation and then return to the area 
in the lungs adjacent to the focus from which they 
started. It is a well-known fact that tubercle bacilli 
keep away from the blood stream, and I believe 
the best explanation of a cavity formation is that 
a single tubercle may have such a strong reaction 
that the cells nearby are killed and the surrounding 
cells are sensitized and the inflammation is in- 
creased. If another severe reaction follows, as a 
result of injection of tuberculin or strenuous exer- 
cise, these sensitized cells are destroyed and even- 
tually, if reactions occur often enough, a large cir- 
cumscribed area of dead tissue ensues, which may 
liquefy or eventually contain mixed infection organ- 
isms, these eventually emptying into a bronchus. 
In other words, a cavity is formed as a result of 
tuberculin circulating around sensitized cells. In 
cases of numerous tubercles coalescing, a very 
large cavity results. If the above reactions are not 
severe, the inflammation resulting causes increased 
fibrosis. 

The amount of fibrosis a person has, determines 
his ability to get over infections of tubercle bacilli, 
a reaction being occasionally the best thing for a 
tuberculous lesion, since it increases the fibrosis. 



52 Practical Tuberculosis 

The amount of fibrosis seen in many advanced 
cases that give histories of repeated reactions, 
seems to warrant this theory, and the difficult part 
in causing these reactions is not to overdo them. 
Koch overdid his reactions by giving tuberculin; 
others today are doing the same as Koch. 



CHAPTEE VIII 

PHYSIOLOGY OF TUBEECULOSIS 

In order that one may treat tuberculosis intelli- 
gently and successfully, a knowledge of the normal 
functions of the body is absolutely essential. One 
must know the effect of exercise and rest on the 
diseased areas in the lungs as well as on the symp- 
toms produced by these diseased areas. On the 
other hand, one must know the beneficial eff ects of 
exercise on the body functions in a tuberculosis 
patient when exercise is indicated. 

The physiologic effects of the increased elimi- 
nation by medicines, exercises, the hydrotherapeu- 
tic measures, as well as the effects of different 
diets, must be thoroughly understood. 

Tuberculosis is a disease in which the energy of 
the one affected must be considered. The decision 
to reach is whether the patient needs to conserve 
his energy or to increase the same. The ultimate 
usefulness of the patient to himself and to the com- 
munity depends on whether he is advised to exer- 
cise at the proper time, developing useless fat 
tissue into useful muscle tissue, or whether he is 
ordered to rest, thereby conserving his energy. At 
the same time that energy is being considered the 
mechanical effect of increased or decreased activity 
on the lungs should also be given thought. 

53 



54 Practical Tuberculosis 

The physiologic effects of worry, fright and 
other causes of increased function of the nervous 
system are often considerations which determine 
the prognosis and treatment. Whether it will be 
best for the patient to lie in bed, thinking, rolling 
and tossing, or whether he will do better if sitting 
up or doing some light exercise, should be decided. 

The heat of the body must be considered, and the 
matter as to whether the patient in question needs 
to go to a warm climate for the winter and how 
much artificial heat he should use must be deter- 
mined. 

In fact, we must try to approach the physiologic, 
all the time keeping in mind the fact that the phys- 
iologic may increase the pathologic, and that at 
times it will be compulsory to so treat the patient 
that the normal functions of the body will be de- 
creased in their intensity. 

A brief consideration of the anatomic makeup of 
the pulmonary apparatus is essential before its 
functions can be properly understood. The appa- 
ratus consists of (1) the air passages — nose, 
pharynx, larynx, trachea, and the bronchi which 
communicate with the lungs; (2) the lungs with 
their immense number of small sacs known as the 
air vesicles; and (3) the thorax. 

We can dismiss the subject of (1) air passages 
with the explanation that they are lined with mu- 
cous membrane which is ciliated in the normal per- 



Physiology 55 

son, thereby assisting in the prevention of foreign 
substances entering the air vesicles. 

The lungs are in the thorax one on each side, 
separated by the heart and large blood vessels. 
They are free and attached only by their roots, 
which are placed near the middle of the lung inter- 
nally and consist of the bronchi, the pulmonary 
arteries and veins, the blood vessels of the bronchi, 
nerves and lymphatics, all invested with a reflection 
of the pleura. They are closely invested by a 
serous membrane, the pleura, which at the root of 
the lung is reflected, covering the inside of the 
chest wall and forming between these two layers 
the pleural cavity which, in the normal state, is a 
closed sac the sides of which rub across each 
other. "When there is a pleurisy these two layers 
become inflamed and often adhere, causing severe 
pain on inspiration. 

The right lung has three lobes, while the left has 
only two. The right lung is shorter and a little 
heavier than the left. 

Lung tissue is very elastic and collapses when re- 
moved from the chest. The lung assumes its shape 
in the chest by virtue of the negative pressure in 
the pleural cavity. It does not move of its own 
accord, but its movements are influenced by those 
of the thorax. 

Inspiration is voluntary, while expiration is due 
to the elasticity of the lung tissue and also to the 



56 Practical Tuberculosis 

contraction of some of the chest muscles and dia- 
phragm. 

The air vesicles are of chief concern from a 
standpoint of physiology. As the air passages 
gradually get smaller and branch off, the bronchi 
are reached. These bronchi have further branch- 
ings until finally each tube is reduced to a diameter 
of about 1-50 inch, and is called a bronchiole. These 
bronchioles then open into blind spaces called in- 
fundibula which are lined with air cells. In the 
walls of these air cells there exists a dense capil- 
lary network, so that we have an alveolar wall sep- 
arating the blood in the capillaries from the air in 
the vesicles. Through this wall, interchange of 
gases takes place, the oxygen of the air passing 
through, uniting with the hemoglobin of the red 
blood cells, and the carbon dioxide of the blood 
passing through the alveolar wall to be expired. 

The blood to the lungs is supplied through the 
pulmonary and bronchial arteries. The bronchial 
arteries furnish nutriment for the lung tissue, while 
the pulmonary arteries supply venous blood from 
the right side of the heart, which is purified by tak- 
ing in of oxygen and liberation of carbon dioxide. 
It is estimated that 6,000 liters of blood pass 
through the lungs in twenty-four hours. 

The lymphatics of the lung are very numerous 
and are arranged in superficial and deep systems 
which terminate in the bronchial glands. 



Physiology 57 

If respiration be suspended but a very short 
time, there will soon be a marked feeling of anxiety, 
due to the nonsatisfaction of an imperative need. 
This sensation is considered due to stimulation of 
the respiratory centers by the carbon dioxide in 
the blood and it is relieved by introduction of air 
into the lungs. When the air inspired and retained 
becomes unfit for further oxidation, there arises 
another internal sensation which calls for the ex- 
pulsion of that same air. 

These two movements constitute, by their regu- 
lar succession, a complete respiration and are 
named inspiration and expiration, respectively. 
The movements of the lungs are passive, being de- 
pendent upon the movement of the thoracic wall. 
The diaphragm is the chief motive agent in inspi- 
ration. This muscle is assisted in its action by the 
internal intercostals, long and short elevators of 
the ribs, and the external intercostal. Expiration 
when forced, has as its causative agents the in- 
ternal intercostals, the triangular sterni, the two 
oblique and transverse muscles of the abdomen — 
Serratus posterior inferior and Quadratus lum- 
borum. 

There are different types of respiration : the ab- 
dominal, found among children ; the inferior costal, 
man's type; and the superior costal or clavicular 
type, which is the mode of respiration peculiar to 
women. In the abdominal type the respiratory 
acts are revealed only by the movements of the ab- 



58 Practical Tuberculosis 

dominal wall; in the inferior costal type the res- 
piratory movements take place especially at the 
level of the lower ribs, beginning with the seventh. 
Finally, in the superior costal or clavicular type, 
the respiratory movements are very manifest only 
about the upper ribs, especially the first. The clav- 
icle also participates in this movement. 

Inspiration is slightly shorter than expiration, 
inspiration being to expiration as 5 to 6. Immedi- 
ately following expiration there is a slight pause. 

Respiratory Sounds 

If a stethoscope is applied over the lung at a 
point some distance away from the bronchial tubes 
and trachea, a sound will be heard resembling the 
rustling of leaves in a slight wind. This sound is 
heard during the whole inspiration and is followed 
by a short expiratory sound. The inspiratory 
sound is three times the length of the expiratory 
and is supposed to arise from the passing of air 
into and out of the air vesicles, the friction here 
generating a sound, aided by the sudden dilatation 
of the air vesicles. 

If now the stethoscope is placed over the trachea, 
two sounds are heard: one during inspiration, the 
longer, and of a tubular quality, the other during 
expiration, which is tubular but more intense, and 
frequently of higher pitch than the inspiratory 
sound. 



Physiology 59 

In the healthy adult male about 20 c c. of air are 
introduced into the lungs and bronchial tubes dur- 
ing each inspiration. At each normal respiration 
of atmospheric air but one-sixth of the air within 
the lungs is changed. The inspired air contains 20 
per cent oxygen, a trace of carbon dioxide, and 80 
per cent nitrogen, with a small amount of water 
and other components in very small proportions. 
Expired air contains 16 per cent oxygen, 4 per cent 
carbon dioxide, and 80 per cent nitrogen, as well as 
a variable amount of water. Heat leaves the body, 
to a great extent, by way of expired air. 

In the adult the number of respirations per 
minute may vary from sixteen to twenty-four. The 
heart usually beats four times during each respi- 
ration. In the recumbent position there are usually 
thirteen respirations per minute, and nineteen and 
twenty-two respirations per minute respectively 
in the sitting posture and while standing. 

During infancy and childhood the number of 
respirations is always greater than in the adult. 
Exercise increases respiration, both as to number 
and depth. Respirations are increased during 
fever or as a result of pleurisy, pneumonia, some 
heart diseases and anemia. 

A sigh is a form of respiration, reflex in charac- 
ter, due to accumulation of venous blood in the 
right heart. Emotions of sadness in their effect on 
oxidation of the blood explain the sighing during 
these emotional states. The yawn differs from the 



60 Practical Tuberculosis 

sigh in its mechanism, but its cause is due to needs 
of oxidation of the blood. The sigh may be 
voluntary. The hiccough is a spasmodic contrac- 
tion of the diaphragm, with coincident contraction 
of the glottis. 

Coughing results usually from an irritation in 
the laryngeal passages. The so-called stomach 
cough for all practical purposes does not exist. 

Laughing and sobbing act especially upon the 
diaphragm. Snoring is due to a vibration of the 
soft palate, and occurs more frequently in people 
who sleep on their backs and in very fleshy people. 

The interchanges of gases at the alveloar wall is 
termed external respiration, while the chemical 
changes in the tissues are called internal or tissue 
respirations. The oxygen, in tissue respiration, 
passes from the hemoglobin to the plasma, then to 
the lymph, and from the lymph to the cells of the 
tissues. The carbon dioxide goes from the tissues 
to the lymph, then to the plasma of the blood. The 
exchange depends upon the law of "dissociation of 
gases/ ' 

Exercise increases the formation of carbon di- 
oxide and other products of metabolism. At the 
same time that oxidation is increased the amount 
of blood to the organs is also increased, and, as 
a result, more energy in the form of heat and power 
to do work is formed. Exercise develops useless 
fat into muscles and, by increasing the elimination 



* 



Physiology 61 

of carbon dioxide, increases, at the same time, the 
appetite. 

The action of the eliminative and digestive 
organs is intensified by exercise. 

In the case of the tuberculosis patient who has 
an active lesion, exercise by increasing the activity 
of the inflamed organ increases the inflammation, 
at the same time causing by increased circulation, 
a flushing out of the infected areas and a scatter- 
ing of the disease. If the exercise is slight and the 
muscular contractions not too rapid, a slight re- 
action occurs in the cells of the body in general, as 
well as at the site of the tuberculous lesion. The 
slight reaction around the tubercles promotes fi- 
brosis, while the cellular reaction develops the anti- 
bodies to tuberculin. 

The effects of abnormal nerve excitants, such as 
worry, fright, anger and home-sickness, are very 
marked in the tuberculosis patient whose nerve 
cells are overstimulated by toxins. Eapid respi- 
ration and circulation, vasomotor circulatory dis- 
turbances, and interference with the normal func- 
tions of the digestive organs frequently follow 
these excitations. 

The will, the normal excitant of the nervous sys- 
tem, plays an important and often decisive part as 
to whether the tuberculosis patient will live or die. 
Will power is apparently increased by suggestion. 
The determined patient who controls himself 
makes the most improvement. 



62 Practical Tuberculosis 

The heat regulating centers of the nervous sys- 
tem control normally the heat reaction of the body. 
In tuberculosis, before immunity is developed, 
there is an increased heat production in the body 
and overstimulation of the heat centers, with ele- 
vation of temperature. If the toxemia is marked, 
as in the last stages of tuberculosis, the sweat 
glands are stimulated to activity and the " night 
sweats" occur, ridding the body of toxins and at 
the same time cooling the body by evaporation. 

On account of the development of antibodies to 
tuberculin and tubercle bacilli it is possible to have 
active tuberculosis without an exhibition of fever. 

Tuberculosis patients often lower their temper- 
ature by exercise. This condition is probably due 
to an increase in heat radiation. 

Warm baths stimulate the circulatory system 
and increase the activity of the skin. Cold baths, 
if of short duration, stimulate the skin and super- 
ficial blood vessels. If, however, the cold bath is 
prolonged, it results in a contraction of the super- 
ficial vessels and has a bad effect. 

Lying on the right side after eating helps diges- 
tion by promoting peristalsis. Fruits and vege- 
tables also promote elimination. Sodium phos- 
phate, by its action on the liver cells, increases the 
elimination of bile. The use of two or three quarts 
of water daily helps to flush the system. Fats, 
carbohydrates and proteids are all needed in the 
reconstruction of the tuberculosis patient. At 



Physiology 63 

times, on account of weakness, or digestive disturb- 
ances, a milk diet is necessary and has given excel- 
lent results in very weak cases. Oil rubs are very 
efficacious in very poorly nourished patients. Each 
case of tuberculosis, being a case unto itself, de- 
mands special treatment to be decided upon by the 
merits of that particular case. 



CHAPTER IX 

TREATMENT OF TUBERCULOSIS 

Broadly stated the treatment of tuberculosis 
should be that which most nearly approaches the 
physiologic. In general, we must treat the disease 
process itself as well as the individual. 

There are two classes of cases to be considered: 
the hopeless, incurable case and the case that gives 
some hope of an arrest of the disease. The treat- 
ment of the hopeless, incurable case in which none 
of our adjuvant treatments is indicated, is to make 
the patient comfortable and at the same time re- 
move all possibilities of his infecting his relatives 
and friends. The advanced case of this type needs 
a great amount of nursing. Resorting to the use 
of opiates should be delayed as long as possible, be- 
cause frequently opiates prolong the life of these 
hopeless incurable cases, who have an impaired 
mind which causes them and their associates much 
discomfort. 

Frequently the apparently hopelessly incurable 
case deceives the physician and gets better. On the 
other hand, as a result of the development of un- 
foreseen complications, the apparently hopeful case 
becomes hopelessly incurable. This condition may 
result from a ruptured lung and its sequelae, or 
from hemorrhage producing a caseous pneumonia ; 

64 



Treatment 65 

or from the ruptured tubercle into the blood 
stream, producing miliary tuberculosis. We often 
see these complications arise and are reminded of 
Dr. Allen K. Krause's statement regarding the ac- 
cidental death in tuberculosis. 

In the treatment of tuberculosis we must use 
nature's processes of rest, fresh air, food, sunshine 
and optimism. The amount of rest must be quali- 
fied according to the demands of the case. We 
must realize that it is the physiologic which we are 
striving for regarding the food, fresh air and sun- 
shine, while rest has for its object conservation of 
energy and decreased activity of the infected area, 
with resulting decrease in inflammation or ulcera- 
tion, as the case may be. At the same time toxemia 
is being diminished by decreasing the amount of 
poison-loaded blood from leaving the infected area 
and also decreasing its rapidity of the flow by rest- 
ing the heart. 

It is impossible to particularize on rest or exer- 
cise when considering patients collectively, and 
specialists of today do not consider the rest treat- 
ments in the same light ; some believe in prolonged 
rest regardless of the symptoms and others take a 
more radical view and believe in approaching the 
physiologic. One cannot go by the temperature or 
cough alone in deciding on the amount of rest and 
it is only by a consideration of all the factors in the 
case, and then a consideration of the object sought, 
that one can decide the amount of rest or exercise 



66 Practical Tuberculosis 

which is best for the case ; and even then mistakes 
may be made, and often the physician is put to the 
greatest test to ascertain what a patient can do. 

The general practitioner should rely on rest in 
the treatment of his cases, and after consulting 
with the specialist he can determine when to exer- 
cise his patient and to what extent. The object of 
rest is to conserve energy and to rest the affected 
lung. The object of exercise is to produce normal 
functions of the body, but not to the extent of in- 
creasing the pathologic conditions. Having the 
patient lie on the affected side is a great help un- 
less it causes an undue cough. Binders and ad- 
hesive strips often help, not only a pleuritic con- 
dition, but also the disease process itself by 
mechanically resting the part. 

Rest decreases the cough and sputum, stops 
night sweats, decreases the pulse and temperature, 
conserves energy, relieves the poisoned mind and 
promotes fibrosis. Exercise at the right time in- 
creases the appetite, converts useless fatty depos- 
its into useful muscle tissue, increases elimination 
and oxidation, and in the proper cases gives the 
patient a different mental attitude, which is often 
the deciding factor in the future course and termi- 
nation of the disease. 

Some authors do not believe in the use of blood 
and general tonics, and this to a great extent seems 
correct. However, the use of iron is, I firmly be- 
lieve, indicated, and my experience has been that 



Treatment 67 

iron administered liypodermically is to be preferred 
both for its physiologic and psychologic effects. 

In the cases with marked nervous irritability use 
of bromides is necessary not to mask the symptoms 
but to use as an adjuvant to Nature's processes. 

It is extremely difficult to decide in many cases 
just how to approach a patient regarding his con- 
dition. The best policy to follow is to be absolutely 
frank with those whom you think can be helped by 
treatment, so that they will not in their ignorance 
do away with their own chances of becoming cured 
by unconscious harmful acts. It is best to hedge a 
little with those you think will die, but as regards 
their relatives it is best to tell the truth, as near as 
possible. 

Optimism is absolutely essential for the tuber- 
culosis patient; and a little talk, with explanation 
of the different phases of the disease, will act like 
a powerful tonic, both physically and mentally. 
Many good results obtained in tuberculosis are due 
to tactful and diplomatic nurses. A nurse who has 
had tuberculosis, if well enough, makes the best 
nurse, as a rule, for the tuberculosis patient. 

The hospital treatment of the tuberculous has for 
its object the isolation of the patient, because of 
his being a focus of infection, and the care and 
comfort of the individual. The sanatorium treat- 
ment should have for its aim the education of the 
patient and not his cure, since it is impractical for 
a tuberculosis patient to stay in a sanatorium until 



68 Practical Tuberculosis 

cured. Sanatorium life is abnormal and the patient 
gets into a rut if he stays too long. However, the 
patient should stay in a sanatorium until he de- 
velops the "habit" and gets his bearings. It is 
also best for him to get a certain amount of exer- 
cise under the supervision of the sanatorium physi- 
cian. There are other unfortunate complications, 
which need not be touched upon : natural perhaps, 
but nevertheless to be avoided for one who stays 
too long in a sanatorium. 

We are often called upon to treat the symptoms 
in tuberculosis to the utter disregard of the disease 
process itself. By such treatments we often mask 
the symptoms and increase the disease, but at times 
it is necessary to treat the symptoms in a given 
case though not losing sight of the disease process 
and the value of rest, fresh air, food, sunlight and 
optimism. These symptoms, as a rule, are cough, 
pain and hemorrhage, for all of which we must, in 
addition to our medical treatment, prescribe rest. 

If a patient has a more or less incessant cough, 
not due to throat irritation, which can be remedied, 
and the cough is not productive, some very mild 
sedative should occasionally be given until the 
physiologic effects of rest have caused a removal 
of the cause. The type of cough with profuse ex- 
pectoration needs some medicine at times to de- 
crease the sputum and at the same time relieve 
the cough. Elixir of heroin and terpin hydrate are 
very useful remedies for this type of cough, as 



Treatment 69 

heroin relieves irritation and terpin hydrate de- 
creases expectoration without increasing the in- 
flammation, as do the iodides. The type of cough 
which is productive after much effort, needs some 
of the so-called expectorant treatment, and the am- 
monium salts work very well in these cases. The 
mistake that the physicians often make, is to allow 
their patients to take medicines for cough continu- 
ally for weeks on end, instead of trying them out 
at the end of a week without medicine. 

About 90 per cent of the cough in tuberculosis is 
probably unnecessary, but is the result of a de- 
veloped habit in the patient. The patient can be 
educated to stop a large amount of this and at the 
same time be taught to cough properly, that is, to 
cough at the end of expiration, thereby relieving 
the strain on the distended lungs, which follows a 
cough during inspiration. It is remarkable what 
prompt relief from coughing results when a patient 
is put at rest in the fresh air. The dry climates 
are wonderful in their effect on cough, and I have 
often remarked the small amount of cough in pa- 
tients in the Southwest as compared with the cough 
of patients in the East and Northwest. 

Hemorrhage from the lungs in the tuberculous 
is a symptom which often is as alarming to the 
physician as to the patient. It is necessary to re- 
call the conditions causing hemorrhage in order to 
treat it successfully and intelligently. There is the 
hemorrhage due to ulceration of the side of a blood 



70 Practical Tuberculosis 

vessel that is of greater or lesser size. The hemor- 
rhage in this case corresponds with the size of the 
rupture as well as with the size of the vessel. Eest 
in bed will usually stop this type of hemorrhage, 
but it may be necessary to give some sedative to 
allay the cough and stop nervousness. The so- 
called toxic bleeding, where there is an occasional 
bright streak of blood intermingled with mucus, 
needs only rest in bed for a few days, depending to 
a great extent also on the other symptoms, as well 
as upon the persistence of the streaking. 

The profuse hemorrhage in cases where there 
are ruptures of aneurysms in cavities usually is 
not amenable to treatment, since the patient is 
asphyxiated in a short time, sometimes even before 
the doctor is called. Most of the cases of this type 
which I have seen, have cried out in a shrill tone be- 
fore the hemorrhage. I do not recall but one case 
of what was probably a ruptured aneurysm, which 
recovered from the hemorrhage, although a few 
cases have lived for a few days by being turned so 
that the blood would run out of the bronchial tubes 
and air allowed to enter. Inhalations of amyl ni- 
trite can be used in these cases if one gets a chance 
to use it. There is another type of bleeding in which 
a cavity is gradually and slowly filled with blood 
from proliferated blood vessels that have ulcerated 
at their ends in the cavity walls, and this type of 
hemorrhage needs only rest. If there is a per- 
sistent bleeding with a large loss of blood, which 



Treatment 71 

loss may be slow or rapid, artificial pneumothorax 
is indicated, if the bleeding point can be de- 
termined. It has given good results in many cases. 

A number of medicinal agents have been given 
routinely in hemorrhage and it is possible that there 
are as many different treatments for hemorrhage as 
there are specialists on tuberculosis. Some resort 
to the use of morphine as a routine treatment; 
others believe in the use of large doses of atropine 
hypodermically ; and good results have been re- 
ported following the hypodermic use of this remedy 
in doses of as large as %5 gr., repeated every six 
hours. Emetin and nitroglycerine, as well as the 
nitrites, have been used. Different agents to in- 
crease the coagulability of the blood, such as lime 
salts, and normal serum, have been used with vary- 
ing degrees of success. It was formerly thought 
that it was necessary to reduce the blood pressure, 
but in a recent series of cases in which I was in- 
terested, it was found that the blood pressure was 
the lowest before hemorrhage and highest follow- 
ing stoppage. 

In treating hemorrhage the physiologic effect of 
nervousness on the heart and lungs should be taken 
into consideration, and every possible method 
should be made to quiet the patient. 

A hemorrhage patient should be put to bed with 
clothing loosened or removed, with as little disturb- 
ance to the patient as possible. The patient is 
usually very nervous and wants the doctor. He 



72 Practical Tuberculosis 

must be assured that if lie will do as told, the 
hemorrhage will stop. He must be encouraged and 
his nervousness must be overcome, sometimes by 
the use of a sedative. I prefer as a sedative, y± gr. 
of codeine given hypodermically. The application 
of an ice bag to the heart region is also a great 
help, as well as the administration of a sedative the 
dose of which depends upon the individual case. It 
is almost criminal to start such cases out, as a rou- 
tine, with a large dose of morphine. Posthemor- 
rhagic pneumonias have been attributed to the re- 
tention of secretions in the bronchial tubes, result- 
ing from the paralyzing effects of morphine on the 
reflexes in these tubes. Even though these post- 
hemorrhagic pneumonias could be proved not due 
to the effects of morphine, there is evidence enough 
against morphine as a routine treatment, in its 
effect on the normal functions of the body, to cause 
it to be discarded. There are many patients, how- 
ever, particularly nervous patients, who will tear 
the rupture in the blood vessel wide open, if not 
given a large dose of sedative. In such instances 
we must choose the lesser of the two evils. 

Magnesium sulphate should be given both for its 
eliminant effect, and also for its effect in increasing 
the coagulability of the blood. The physician must 
use good common sense in giving magnesium sul- 
phate. It should not be given immediately to a 
patient who is already nauseated or to one who has 
just had a heavy meal. In fact it is best to wait 



Treatment 73 

a few hours, at least after hemorrhage, before giv- 
ing the salts. 

After one has seen many cases of tuberculosis, 
many of them of the hemorrhage type, one is im- 
pressed with the idea that probably almost all 
hemorrhages which stop with medicinal treatment 
would stop without it, if the patient is put to bed, 
reassured and encouraged. Diet in hemorrhages 
has received much attention. From a practical 
standpoint it would seem best not to give too much 
food to hemorrhage patients, and nothing hot, in- 
digestible, or of a makeup that would increase 
cough. A small amount of very easily digested 
food, not hot, will suffice, and sometimes it will be 
best to give only fruit juices for a short time. 
Grape juice, being of a high caloric value, is good. 

When to allow the patient to get out of bed fol- 
lowing hemorrhage, is to be determined by the use 
of common sense and the experience gained by ob- 
servation of previous cases. It is best to wait at 
least five days after all bright hemorrhage has 
stopped, and the getting up should be very gradual, 
depending upon the strength of the patient. The 
patient should at first try to turn from one side to 
the other if the hemorrhage has been enough to 
compel absolute immobilization, and then gradu- 
ally sit up in bed. 

Pain in the chest is often a troublesome symptom 
in the tuberculous, not always because of the 
amount of physical suffering, but sometimes more 



74 Practical Tuberculosis 

on account of the psychic effects that it has on the 
patient. The patient will mention it because he 
wants to be reassured that he is not getting worse; 
and he will usually say that it does not bother him 
enough to have anything done for it, after he has 
been told that it is only a slight inflammation that 
will subside and perhaps help his healing process. 
Other cases of moderate severity need some relief, 
such as is obtained from the use of the hot water 
bag or iodine; still others, who have an adhesive 
pleurisy with the sharp knife-like pains, need to 
have the chest immobilized. Adhesive plasters and 
binders applied tightly are a great blessing in this 
form of pain. It is sometimes necessary to give a 
narcotic to these patients, as well as to strap them. 
Having the patient lie on the side where the pain 
is located, will often relieve the pain due to rubbing 
of the inflamed pleurae, because it stops the motion 
and rests them. 

Dr. John B. Hawes suggested the probability of 
pain in the chest being due to the mechanical effect 
of pressure on the nerves in a process of healing. 
It is possible to get a burning sensation in a lung 
free from disease as a result of circulation of tuber- 
culin from the sick lung to the sensitized cells of 
the well lung, especially following exercise. This 
phenomenon is similar in its reaction . to the 
cutaneous skin test, in which case there is an in- 
flammation with all its cardinal symptoms, in a 



Treatment 75 

group of cells that are well, although sensitized to 
tuberculin. 

Patients often come to me with a story of a 
diagnosis, by their doctor, of tuberculosis on the 
right or left side, and examination shows the great- 
est amount of trouble to be on the opposite side. 
Further questioning brings out the fact that the 
patient had complained of pain in the lung in ques- 
tion, and the physician had diagnosed the trouble 
as being in this certain lung, presumably from the 
subjective symptoms. This is, to a certain extent, 
as it should be ; and it is to be hoped that the phy- 
sician of the future will continue to consider these 
and other subjective signs, and not rely too much 
on the stethoscope and microscope. 

In treating any symptoms of tuberculosis we 
should try to avoid the use of medicines as much 
as possible, and rely more on treatments which will 
act physiologically and mechanically in removing 
the disease and its cause. Many drug addicts blame 
their weakness on the use of morphia in the treat- 
ment of a previous tuberculous infection; it is con- 
venient to have someone to blame for our faults. 
Seriously, this is probably a true picture, to a cer- 
tain extent, of conditions as they exist, and care 
should be taken that such ♦ complications do not 
occur in the future. 

Night sweats are at times troublesome symptoms 
of tuberculosis to overcome, but rest, by decreasing 
the toxemia, decreases this symptom. We are re- 



76 Practical Tuberculosis 

minded of the old treatment of placing a pan full 
of water under the bed and going to bed as a 
remedy for night sweats. This perhaps was based 
on actual experience; but instead of rest getting the 
main credit, the water under the bed was con- 
sidered the agent causing this mysterious relief. 
At times it is necessary to resort to hydrotherapy 
in the treatment of night sweats, for which an oc- 
casional dose of atropine is very efficacious. 

The tuberculosis patient must have good elimi- 
nation, and the use of natural laxatives, such as 
bran, mineral oil, fresh and dried fruits, is to be 
strongly encouraged, as well as an occasional dose 
of castor oil. Sodium phosphate, by its action on 
the liver, is a very necessary medicinal agent in the 
tuberculous, who, through sedentary habits and 
a diet rich in carbohydrates, has a sluggish liver. 

Gastrointestinal disorders need attention quite 
frequently, and often a patient's digestive system 
needs rest after being clogged with food by the 
patient, who thinks he must stuff to get well. It 
is well to treat these disturbances with rest, giving 
a small amount of milk for a day or so, in conjunc- 
tion with other medicinal agents which may be in- 
dicated. 

The physician who will use just as little medicine 
as possible, with as much encouragement and good 
sound advice regarding the use of Nature's proc- 
esses of rest, fresh air, optimism and sunshine, 
will get better results than the one who is continu- 



Treatment 



77 







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78 Practical Tuberculosis 

ally using any remedy that comes on the market 
that has not been approved by the American Medi- 
cal Association or the National Tuberculosis Asso- 
ciation. 

Instructing the patient in regard to the history, 
diagnosis, prognosis, prevention and treatment of 
the disease will help him wonderfully, and will also 
refresh the physician's mind on the different 
phases of the disease. Furthermore, it also instils 
confidence in the physician. 

A patient who takes a few months' treatment, 
and is not responding as he should, needs the ad- 
vantage of a consultation with a specialist, who can 
often recommend some special line of treatment 
or some change in his present treatment. Such 
special treatment may be artificial pneumothorax, 
tuberculin, vaccine, or surgery. Such special treat- 
ment should be administered by the specialist or 
given under his direction. 



CHAPTER X 

TREATMENT OF COMPLICATIONS IN 
TUBERCULOSIS 

The treatment of nontuberculous complications 
in the tuberculous is, as a rule, the same as for these 
conditions in the nontuberculous. However, it 
should be the object of the physician to conserve the 
energy of his patient in every way possible and to 
avoid undue shock. Tuberculosis patients with 
simple colds should be treated with bed rest during 
such attacks, because often these colds untreated 
in this way have apparently increased the activity 
of the tuberculous infection. This has been shown 
to be true, especially during the epidemics of in- 
fluenza. Anesthetics should be used sparingly. 
Ether has apparently been the cause of many 
deaths in tuberculosis patients. 

Tuberculosis of the bone and joints needs rest, 
preferably by the use of the plaster jacket, and 
these cases should also be under the expert atten- 
tion of the orthopedist. Heliotherapy should be 
used, especially in open cases. 

Glandular tuberculosis sometimes demands sur- 
gical interference, but radical operations would 
seem best to be avoided. A few such cases have 
made great improvement under tuberculin treat- 
ment. 

79 



80 Practical Tuberculosis 

The use of tuberculin has yielded good results in 
renal tuberculosis. Dr. John B. Hawes, who has 
had a very wide experience in this form of tuber- 
culosis, is very enthusiastic in its use and his re- 
sults surely justify his enthusiasm. Surgical inter- 
ference is at times very necessary in these cases, 
as a rule, due to delayed diagnosis. Eecent post- 
mortem reports seem to prove that these infections 
heal spontaneously more often than we formerly 
imagined, and that this may also be the case in 
liver and meningeal tuberculosis. 

Asthma is a frequent complication of tuberculo- 
sis, especially in tuberculous women at the men- 
strual period. Autogenous vaccines have appar- 
ently been of some help in overcoming these con- 
ditions, after all possible focal infections have been 
eliminated. 

Tuberculous pneumonia, while usually running 
a rapid and fatal course, does in some cases settle 
down to a chronic process. I have treated such 
cases with artificial pneumothorax with good re- 
sults. 

Pleural effusion is often a troublesome compli- 
cation and one which is often difficult of treatment. 
If, however, dyspnea, pain in the chest or displace- 
ment of the heart is marked, removal of the fluid 
by aspiration is indicated, and one feels well repaid 
for the interference when he sees the marked relief 
that it affords these cases. I have often instilled 
one-half as much air as fluid removed in such cases. 



Treatment of Complications 81 

This was done to keep the pleural surfaces sepa- 
rated and also to support the lung. About 20 per 
cent of my cases treated by artificial pneumothorax 
developed a pleural effusion which, in a few cases, 
became purulent. 

Empyema should be treated by withdrawal of the 
fluid at different intervals, and by washing out the 
pleural cavity with some of the antiseptics which 
the army surgeons have found effective. I believe 
that rib resection has been resorted to too often in 
some of the serious cases, and that aspiration would 
have been more satisfactory. 

Peritoneal tuberculosis is often cured spon- 
taneously, but in cases of extreme pressure, opening 
of the abdomen and draining are usually all the 
treatment that is necessary. 

Intestinal tuberculosis, surgically treated, has 
not given promising results. These cases usually 
do well, with the exception of the interference in 
the bowel function, and of some pain when the 
bowel contents pass over the inflamed area. I be- 
lieve this sensation in the intestines is often more 
annoying than painful, similar to the pain in the 
chest. If a person's resistance is good, the mechan- 
ical walling off of the focus proceeds satisfactorily, 
and if the cellular resistance is poor we get ulcera- 
tion with all that that entails. It has been shown 
that tuberculosis of the intestines occurs as a pri- 
mary or secondary condition in from 30 to 90 per 
cent of all cases of pulmonary tuberculosis. The 



82 Practical Tuberculosis 

treatment is really expectant and symptomatic, ac- 
cording to whether there is diarrhea, constipation 
or pain accompanying the affection. The diet must 
be of a very digestible nature, and preferably not 
too much liquid. Bismuth preparations, iodoform, 
and the astringents have been used, both in com- 
bination with opiates, and alone. 

Spontaneous pneumothorax is a rather infre- 
quent complication of pulmonary tuberculosis. 
The diagnosis, prognosis and treatment of this con- 
dition depend upon whether the pneumothorax is 
complete or partial, and whether the opening in 
the rupture area is valvular or whether it has 
closed. The partial pneumothorax is the result of 
adhesions limiting the escape of the air into the 
pleural cavity, and is therefore localized. If the 
opening is not valvular, the prognosis is good and 
the treatment is rest. If there is a valvular open- 
ing, it is often necessary to withdraw the air, in 
left-sided cases especially, where there is much dis- 
comfort and heart displacement. In the complete 
type, with a valvular opening, a very troublesome 
complication occurs especially when the rupture is 
on the left side. I have seen six cases during the 
last ten years. It is quite posible, and probable that 
I have overlooked some partial ruptures, especially 
in the far advanced, where, on account of adhesions, 
the rupture did not produce much discomfort. The 
following is a brief history of these cases : 



Treatment of Complications 83 

Case I. — Male, moderately advanced case, upper two-thirds of 
lung infected, and scattered areas in right. Complained of sharp 
pain in left lung at the top; appeared very nervous, dyspneic, and 
was cyanotic. Examination showed complete valvular pneumo- 
thorax, left side, with heart pushed entirely over to the right chest. 
Patient died two days later. 

Case II. — Female, advanced case, both lungs entirely infected. 
During a coughing attack she experienced severe pain in the right 
lung; was very nervous and short of breath. Patient died in 
twenty-four hours. Examination showed right complete pneumo- 
thorax. 

Case III. — Male, advanced case, right lung entirely infected, 
with area scattered in left. After a severe coughing spell he expec- 
torated a small amount of bright blood, and complained of severe 
pain in the right chest. Patient very nervous and short of breath; 
temperature and pulse elevated. Examination showed complete 
pneumothorax of the right side. Patient gradually improved, but 
six months later developed an empyema, which eventually resulted 
in death. 

Case IV. — Male, moderately advanced case, upper two-thirds of 
right lung infected; left lung contained a few scattered rales. 
After a severe coughing spell patient complained of severe pain in 
the right chest; was short of breath, with elevated temperature 
and pulse, and marked nervousness. After a few hours patient had 
developed a subcutaneous emphysema of the upper part of the 
body on the right side, with marked dyspnea. Examination showed 
a complete rupture, with a valvular opening, on the right side. A 
large cannula and trochar was inserted over the rupture and the 
chest bound down, leaving the cannula in place. Patient made 
good improvement, but developed empyema which still stays with 
him. 

Case V. — Male, moderately advanced, left lung with scattered in- 
fection throughout, with a possible cavity in the lower third. Eight 
lung showed a few scattered areas of infection. After a severe 
coughing attack, patient experienced a severe pain in left chest 
in the area of possible cavitation; was marked by dyspneic, and 
nervous, with elevated temperature and pulse. Examination 
showed left pneumothorax with probable valvular opening. Air 



84 Practical Tuberculosis 

was removed at different intervals. An effusion developed and was 
withdrawn. The pleural space was partly filled with air to take 
the place of the fluid withdrawn, and also to keep the mechanical 
pressure on the opening until it was healed. Patient did well; 
and one year after the rupture is attending to his usual duties as 
a clergyman. 

Case VI. — Male, moderately advanced, both lungs affected in 
upper half. After a severe coughing attack developed sharp pain 
in the left side, with marked shortness of breath and cyanosis. Ex- 
amination showed a complete rupture of the left side with a valvu- 
lar opening. Air was withdrawn at intervals, and the patient is 
doing well. 

In withdrawing air I found it best to withdraw 
as much as possible and not go by the manometric 
readings, since these cases often show marked neg- 
ative pressure and at the same time are very un- 
comfortable. The first few cases that were cited 
occurred a number of years before the artificial 
pneumothorax apparatus was very much used, 
while the last were treated by withdrawing the air 
by reversing the apparatus. The cardinal symp- 
toms in these cases were severe pain following 
cough, marked shortness of breath and nervous- 
ness, sudden elevation of temperature and pulse, 
with the distention of the side where the rupture 
occurred, and marked tympanitic resonance on 
percussion. 

Laryngeal tuberculosis complicates pulmonary 
tuberculosis in 10 to 20 per cent of the cases. Many 
physicians do not believe in treating the laryngeal 
complication except by rest and general building 
up of the body. Best is very important, and it is 



Treatment of Complications 85 

necessary to keep the mucous membranes clean by 
some spray, such as Dobell's solution, especially 
where there is an ulcerative condition. Argyrol is 
a useful application in the inflammatory stage, as 
is also menthol in olive oil, Lugol's solution and a 
few others. Phenol in a 1 per cent solution, for- 
malin in from 1 to 10 per cent solution, lactic acid 
in from 20 to 70 per cent solutions, have all given 
good results in the ulcerative forms. It is neces- 
sary, as a rule, for a throat specialist to diagnose 
these cases, because the general practitioner is 
often not accustomed to the examination of the 
larynx. Every case of pulmonary tuberculosis 
should have a throat examination at intervals, and 
if infected, should be treated. The physiologic 
effects of these throat treatments are to be desired 
even though nothing else results. 

It is generally recognized that when a person has 
one or more infections, one may influence the other 
occasionally, to the apparent advantage of the 
patient, but more frequently the opposite results. 
Vaccination has often lit up tuberculous infections. 
Focal infections, in a great many cases, apparently 
prevent a rapid recovery from tuberculous infec- 
tion until removed, when a speedy improvement 
results. I have noticed that following influenza, 
patients, who have tuberculous infections, and who 
have had a von Pirquet test, would show a reacti- 
vation of the area which was the point of election 
for the skin test, and that this occurred frequently 



86 Practical Tuberculosis 

as long as six months following the test and imme- 
diately following and during the influenza attack. 

According to autopsy reports, there have been 
many cases of meningeal infections in tuberculosis, 
which have not resulted in death, but which have 
spontaneously healed. Young children invariably 
have tuberculous meningitis following infections in 
the lungs, in the cases that have a fatal termination. 
In the young children with meningeal tuberculosis 
there is usually a certain length of time during 
which the child is out of sorts. This period, is 
followed by one with more marked symptoms of 
elevated temperature and rapid pulse, projectile 
vomiting, and marked restlessness, especially at 
night, when the child cries out. The child will 
place his hand over the region of the head where 
the pain is located. Convulsions with temporary 
hemiplegia are often the first definite symptoms. 

Older patients complain of a localized pain in the 
frontal or parietal region. This pain is not relieved 
by any treatment. There is at the same time ele- 
vated temperature and rapid pulse, marked photo- 
phobia and stiffness of the muscles in the back of 
the neck. Kernig's sign, and paralysis of the rec- 
tum and bladder reflexes follow. Lumbar puncture 
has apparently cured some cases of meningeal tu- 
berculosis by relieving the pressure. 



CHAPTER XI 

EXERCISE AND REST IN TUBERCULOSIS 

Exercise and rest are two of the most important 
measures to be considered in the treatment of tuber- 
culosis. There is probably no other agent in the 
treatment of tuberculosis which has caused as much 
harm, when wrongly used, as has exercise. On the 
other hand, when used properly, exercise at the 
proper time has been more beneficial than has rest. 

There are no general rules to be gone by in pre- 
scribing rest and exercise which will apply to every 
case. However, the physician must have some 
guide in prescribing these remedies, and at times 
he will be compelled to go a great deal by the 
patient's statements; but he must be equally care- 
ful in using good common sense, based on his 
knowledge of physiology and the pathology of 
tuberculosis. 

The object of rest is to conserve energy, decrease 
the function of the affected organ, and decrease 
the rapidity of the heart beat, thereby decreasing 
the output of toxins and bacilli from the active foci 
and decreasing all symptoms of the disease by de- 
creasing the activity of the foci. 

The object of exercise is to increase elimination, 
to convert useless fat into useful muscle tissue and 
to increase oxygenation of the blood. In short, we 
must exercise to be normal. 

87 



88 Practical Tuberculosis 

It has been shown that a position of the patient 
with the body at an angle of 30 degrees to the legs 
produces the most complete relaxation. Some 
authors today believe in prolonged bed rest in the 
treatment of tuberculosis. It is not a good idea to 
have a patient, with very little signs of activity, 
lie in bed and get fat and lazy. I have seen a few 
cases where the physician has had his patient lie 
in bed absolutely, until he was so weak and fat 
that it took many weeks of graduated exercise to 
undo the harmful effects of the prolonged rest, so 
far as its effect of weakening the heart muscle was 
concerned. A physician, as I have mentioned be- 
fore, must use common sense. At times a patient 
can rest much better by sitting up in a chair than 
by lying in bed, nervously tossing from side to side. 

As a rule, it is not the work or exercise that a 
patient does, but the way he does it, that deter- 
mines whether the results will be good or bad. 

A patient must exercise slowly, being careful not 
to cause rapid respiration or rapid heart action, 
and not get overtired. A tuberculosis patient, if 
slightly toxic, needs a guardian, since he is very 
nervous and will invariably overexercise. A little 
exercise of the body will often relieve wonderfully 
an overexercised mind, but in cases of extreme 
nervousness, absolute rest and quietude are 
necessary. 

Patients should rest before and after each meal 
for an hour, and they should relax at meals as much 



Exercise and Rest 89 

as possible, so that they can give proper attention 
to their eating. 

Patients should be given their exercise in gradu- 
ated doses. That is to say, if a patient has been 
absolutely in bed, he should be allowed to sit up 
gradually before attempting any walks. If 
patients are very weak, they should at first take 
only a few steps at a time, and gradually increase 
their walking according to their condition. 

A great many cases of tuberculosis are accident- 
ally discovered, and very many of these cases are 
not active and do not need absolute and prolonged 
rest, but do need instruction. The fact that a 
patient has tuberculosis does not make it necessary 
that he be made to lie in bed for six months, unless 
there are some indications for the rest. It is 
suicidal, on the other hand, for a patient to "go 
West and rough it," providing he has symptoms 
of activity. The doctor advising such treatment is 
committing a crime. 

Patients entering the Texas State Sanatorium 
are put to bed, except for meals, if their temper- 
ature and pulse are under one hundred, and if they 
do not have a severe cough, spitting of blood, short- 
ness of breath, marked weakness or other toxic 
symptoms. If they do have the above symptoms 
they are allowed to get up only for the bath and 
toilet. If patients have been taking quite a bit of 
exercise before entering the institution, and if they 
have no marked symptoms of activity, they are 



90 Practical Tuberculosis 

soon given fifteen minutes of exercise, twice daily, 
and are allowed to sit up except for two hours in 
the morning and four hours in the afternoon, which 
time is spent in bed with the patient undressed 
and relaxed. During the afternoon rest hour no 
communication between patients is allowed. 

Friday is set aside as order day, and each patient 
is questioned regarding his general condition; that 
is, whether he feels rested or not, and also regard- 
ing weakness, increase in cough, expectoration of 
blood, pain in the chest and nervousness. If he 
gives a good report, and his temperature and pulse 
are normal, he is allowed a little more exercise once 
or twice a day and a little more sitting-up time. 

Graduation of exercise must be carried on slowly, 
and it is often necessary for a patient to be put 
back to rest. 

Visitors to tuberculosis patients are very harm- 
ful and should be limited to as few as possible, and 
these should be told to stay only a few minutes. 

There are few general rules that can be con- 
sidered regarding the use of exercise. They are as 
follows: 

1. None if temperature is above 99° F. 

2. None if iolood in sputum. 

3. None if loss of weight is persistent. 

4. None if pulse is rapid after a few attempts at 
exercise. 



Exercise and Rest 91 

5. Never get out of breath. 

6. Never get overtired. 

7. Never strain the body lifting or running. 

8. Go slow. 

9. A persistent tired feeling calls for more rest. 



CHAPTER XII 

CLIMATE IN TUBERCULOSIS 

A physician treating tuberculosis patients is 
often asked concerning a change of climate for the 
patient who is not doing well. In order to envis- 
age this subject intelligently, it is necessary to con- 
sider what effect climate has on the body and 
whether the dry climate effect is to be desired or 
the cold climate effect. 

Climate is the sum of all the meteorologic con- 
ditions of a locality. The nearness to bodies of 
water, the latitude and altitude, and prevailing 
winds enter into consideration ; also the amount of 
rainfall and sunshine. 

The physiologic effects of a hot climate are to in- 
crease the activity of the skin and liver, to stimu- 
late the nervous system, and to cause a sluggishness 
of the muscular and digestive systems. 

Cold climate stimulates the muscular and diges- 
tive systems. 

In the treatment of tuberculosis, climate has had 
a varied consideration as to its value, and, in the 
absence of correct data on which to base our ideas 
regarding its value, it seems that this question will 
still receive varied answers. The most unfortunate 
thing that has happened to consumptives is to send 
them to the Southwest without money or acquaint- 

92 



Climate 93 

ances, with the result that they die of starvation 
quicker and with a great deal more suffering than 
they would had they remained at home and taken 
advantage of what Nature had to offer in their 
home towns. Therefore, experience has taught 
us that money is the first consideration in re- 
gard to a change of climate, and that sufficient 
funds to cover all expenses must be arranged 
before the tuberculous person starts on his trip. 
The opportunity to take the treatment under 
a specialist's direction or in a sanatorium must 
be considered. There are thousands of people 
going to the Southwest every year, thinking that 
the air and sunshine will cure them regardless of 
rest, or the guidance of a specialist. 

There is an old saying that if one lives in West 
Texas a year, one will never leave there for good; 
I am sure that this is a fact in a number of in- 
stances. There, it is possible to live in the open 
practically the year round and have the benefits 
of almost continuous sunshine, the effects of which 
can be appreciated when one leaves this beautiful 
country and goes to the Northern or Eastern coun- 
try, especially if one strikes the rainy season. It 
has often been said that a person who has lived in 
the Southwest can never live elsewehere for any 
length of time. It is my idea that if a person has 
this opportunity, he will not have any desire to live 
anywhere else, although if necessity compels him to 
change he can surely do so without harm to himself. 



94 Practical Tuberculosis 

I have noticed that cough and expectoration, as 
well as hemorrhages, are not as marked in the 
Southwest as elsewhere in the states. Body tem- 
peratures are lower and the average tuberculous 
complications are not as frequently found as in the 
Northwestern and Eastern sections, and the mental 
attitude of the patients is something wonderful. 
One can be absolutely frank with patients and they 
do not get excited, as is the case sometimes with 
patients in the Northern climates. I believe that 
the mental attitude, to a great extent, is due to the 
climate which predisposes to health and happiness. 
There are a few weeks in the summer when the 
climate in the Southwest is very hot, but usually 
the humidity is low and a cooling breeze at night 
makes up for any discomfort suffered during an ex- 
tremely hot day. I arrived at the conclusion, after 
studying the question of climate, that a person with 
an ulcerative case of tuberculosis, who has given 
his home climate a thorough trial and at the same 
time kept up the proper standards of treatment, 
such as rest, fresh air, foods, etc., and who is at a 
standstill, will, if he is financially able, do well in 
the Southwest, provided he is under competent 
medical supervision, and has all other necessary 
factors. 

Altitude was formerly thought to be a cure or 
help in the treatment of tuberculosis, and it was 
thought that people living in certain countries at 



Climate 95 

certain altitudes were immune. This idea has been 
proved to be erroneous, since it is possible that al- 
titude is harmful to the advanced cases, or at least 
to some of them, on account of the rarefied con- 
ditions of the air. 



CHAPTER XIII 

ARTIFICIAL PNEUMOTHORAX IN TUBER- 
CULOSIS 

Artificial pneumothorax, as a treatment for tuber- 
culosis, has had its cycle of popularity to the same 
degree as many other treatments for tuberculosis. 
It is impossible to give any definite indications for 
the use of artificial pneumothorax, which will apply 
in every case. It is impossible to tell whether or 
not a complete collapse can be obtained until we 
enter the chest. The use of induced pneumothorax 
is twofold: First, to relieve the disease, and second, 
to stop hemorrhage. In the relief of the diseased 
process the local effect is to decrease the function 
of the lung and to prevent absorption of toxins. 
At the same time that the lung is being rested, re- 
construction of the diseased area is taking place 
and fibrosis developing. In the case of compression 
of cavities, the walls which have been approxi- 
mated, are the site of further healing that w^ill in 
some cases obliterate the cavities. Dr. Allen K. 
Krause has shown that fresh tubercles develop in 
the collapsed lung. 

The stoppage of lymphatic circulation results in 
lessened toxemia, manifested by a decrease in the 
temperature and pulse and general improvements 
in appetite, color and general condition. The im- 

96 



Artificial Pneumothorax 97 

provement that immediately follows in some cases, 
especially the lessened toxemia, is almost miracu- 
lous. At the same time that toxic symptoms are 
lessened, cough and expectoration are decreased 
and, in some cases, immediately disappear. 

The use of artificial pneumothorax should be re- 
stricted to those cases which have been considered 
good cases for its application by a specialist, and it 
should be given by a specialist who has had special 
experience in this line of work, since some unfor- 
seen complication may occur that will change the 
whole aspect of the case, if not met just in the 
right way. It is impossible for the general prac- 
titioner to say when a case should have artificial 
pneumothorax treatment ; in fact, it is often a puz- 
zle to the specialist. There are a few general con- 
siderations which may be considered regarding the 
indications for its use. 

It is the tendency of the physician, on hearing of 
a certain treatment for tuberculosis, to use that 
treatment on all his cases regardless of conse- 
quences, not stopping to think that nature has cured 
hundreds of cases with natural processes. As has 
been mentioned before, this was the case with tu- 
berculin. Artificial pneumothorax has suffered the 
disappointing experience following the use of tu- 
berculin; it has been used promiscuously by some 
with poor results, and the treatment has been def- 
initely discarded as far as they are concerned. 



98 Practical Tuberculosis 

Specialists do not agree today as to when arti- 
ficial pneumothorax should be done; some use it 
early; others as a last resort. 

I believe that I have made the common mistake 
of being too anxious and of using pneumothorax 
too early. At the present time my expeience has 
proved to me that it is best to give a patient a good 
chance first, with every natural treatment, but not 
to wait too long before using the compression treat- 
ment. 

The cases which are to be benefited by pneumo- 
thorax treatments are (1) those cases with con- 
tinuous bleeding; (2) those with more or less high 
fever and quite a large amount of purulent sputum; 
(3) those cases without sputum, but with more or 
less continuous high fever; (4) those cases with 
apparent walling off of their foci, but with profuse 
expectoration and normal temperature. 

I have seen the best results in the second class of 
cases, both as to decreasing the sputum and the 
cough, and also relieving toxemia. In the treat- 
ment of bilateral cases which are not doing well, 
the symptom that is of the greatest value is expec- 
toration. The patient can usually tell where the 
sputum is coming from, and this is of great assist- 
ance in bilateral cases in determining which side to 
go into when pneumothorax is used as a last resort. 

The contraindications in the use of pneumo- 
thorax are : associated organic diseases of the heart, 
liver and kidneys, and also youth and old age. The 



Artificial Pneumothorax 



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100 Practical Tuberculosis 

complications incident to this treatment are: rup- 
ture of the lung, causing hemorrhage, infection of 
the pleural cavity and pleural shock. Puncture of 
the lung can often be avoided by using the clamp 
invented by Dr. Edward Baldwin, which prevents 
the needle from entering the pleural cavity over a 
certain distance. The infection of the pleural cav- 
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As a rule I endeavor to produce a neutral pres- 
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I II 1 1 riTTTTTITTI 

102 






Artificial Pneumothorax 103 

It has been shown that it will take about five 
days to absorb three hundred cubic centimeters 
when the pleura is healthy and longer in inflamed 
pleura, if the inflammation is not acute. In the left 
sided cases the lung must be watched very care- 
fully, as often there is a flexible mediastinum and 
thoracic displacement. Embolism is another com- 
plication that is occasionally met with, but which 
can be avoided by waiting until there is definite 
oscillation of the manometer before instilling air. 

The percentage of cases in w^hich artificial pneu- 
mothorax is indicated at some time during the 
process of the disease is undoubtedly large, and the 
careful administration of this remedy gives prom- 
ising results in carefully selected cases. 



CHAPTER XIV 

TUBERCULIN THERAPY 

Tuberculin is a term used to designate products 
of the tubercle bacillus. It was used by Koch to 
describe his "Old Tuberculin, " but now all of the 
different products of the tubercle bacilli are desig- 
nated under the common heading of tuberculin. 

There are three distinct periods in the history of 
tuberculin therapy. The first began when Koch 
made known his discovery of tuberculin in the year 
1890. At that time the aim was to produce marked 
reactions and to continue the treatment until no 
further reactions were obtained. In lupus, gland- 
ular and bone tuberculosis, 10 mg. and in tuber- 
culosis of the lung, 1 mg. were the initial doses. 
Quite frequently 10 mg. were given to a strong per- 
son and rapidly increased. While Koch soon recog- 
nized that this severe treatment was only suitable 
for the incipient cases, very sick and far advanced 
cases were similarly treated by many physicians. 
Following this procedure decidedly unfavorable re- 
sults were obtained in the advanced cases, and the 
once highly praised remedy was entirely rejected. 

During the second period only a few followers 
of Koch continued their studies on this subject. 
They, however, made it their business to investi- 

104 



Tuberculin Therapy 105 

gate the causes which were responsible for the un- 
favorable results in tuberculin therapy. The 
success of these later investigators brought about 
a revival of interest in this therapy, and it was 
again taken up (third era), and was found that 
in selected cases, if properly given, it was probably 
of great benefit. Unfortunately, we do not know 
when it is exactly indicated; the number of deaths 
that can be traced to the use of tuberculin, in recent 
times by the general practitioner are evidence that 
the treatment should be given only by, or under 
the supervision of the specialist. While it was the 
object of the early workers to produce a strong re- 
action, the general opinion at present is that this 
should be avoided, especially the increase of 
temperature. 

Tuberculin must not be considered a cure for tu- 
berculosis. The question arises whether it is at all 
possible to obtain active immunization by the in- 
jection of an antigen in a condition in which in- 
fection has already taken place and produced 
pathologic changes. The answer to this is to be 
found in Koch's fundamental experiments, which 
constitute the starting point of the entire tuber- 
culin study. 

If a normal guinea-pig is inoculated with tu- 
bercle bacilli, the point of inoculation very soon 
closes. After ten to fourteen days there appears 
at the site of inoculation a small hard nodule which 



106 Practical Tuberculosis 

finally ulcerates. This shows no tendency to heal 
and remains so until the death of the animal. If, 
however, a tuberculous guinea-pig is inoculated in 
the same manner, while the point of inoculation 
closes, no indurated nodule appears. Instead, a 
necrotic process sets in in the skin after the second 
day, which finally terminates in the casting off of 
the slough and the formation of a flat ulceration 
that heals rapidly. It does not matter whether 
living or dead tubercle bacilli are used in the 
second injection. 

Koch further showed that the infection of tuber- 
culous guinea-pigs with large doses of tubercle 
bacilli caused rapid death of the animal, whereas 
frequently repeated small doses evinced favorable 
effects upon the site of the injection, as well as on 
the general condition. 

That tuberculin does not meet the requirements 
of an absolute cure is proved by the fact that an 
animal immunized against tuberculin will not be 
protected against a later infection of living bacilli. 
Hence, it cannot be expected that immunization of 
a tuberculous person with old tuberculin will pro- 
tect him against living tubercle bacilli. 

On examination of the tuberculous organs of an- 
imals treated with tuberculin, there will be found, 
within the healthy tissues surrounding the focus, 
a fresh inflammatory reaction. This consists of a 
serofibrinous exudate and a zone of leucocytes in- 



Tuberculin Therapy 107 

trading to a certain extent npon the tuberculous 
lesion. Tuberculin acts only on living, not necrotic, 
tissue. Koch considered that tuberculin brought 
about death of the tuberculous tissue. 

The general practitioner should never use tu- 
berculin, except under a specialist's supervision. 



CHAPTER XV 

VACCINES IN TUBERCULOSIS 

A few years ago, vaccines were thought to be 
very useful in the treatment of pulmonary tuber- 
culosis. The ulcerative type of case with profuse 
expectoration was treated in this way. 

My experience with 100 cases treated by vaccines 
at the Massachusetts State Sanatorium, Rutland, 
Mass., proved to me that this method of treating 
tuberculosis was not beneficial, and, in some in- 
stances, vaccines have done harm. 

I have used autogenous vaccines and also stock 
vaccines in cases of pulmonary tuberculosis compli- 
cated by mixed infection in the lungs. The result 
obtained with both varieties was about the same. 
In some cases sputum was diminished, but it did 
not entirely disappear. 

Nontuberculous infections in the lungs have 
been greatly benefited by vaccine treatments. 
Focal infections with pulmonary manifestations 
have improved under vaccine treatment. 

Chronic influenza and pneumonia of lungs when 
treated by stock vaccines have shown fine improve- 
ments. 



108 



CHAPTER XVI 

THE USE OF X-RAY IN TUBERCULOSIS ' 

The use of the x-ray in the diagnosis of pulmo- 
nary tuberculosis is increasing in popularity, espe- 
cially from the standpoint of its use by the general 
practitioner. 

"We frequently see cases that have been diag- 
nosed as tuberculosis, as a result of these exami- 
nations, by the general practitioner. In many 
cases, if the examiner had used good common sense, 
he would not have found it necessary to resort to 
the use of the x-ray. 

It has been my experience that many of these 
general practitioners in using this method of exam- 
ination for chest work make a serious mistake 
since they do not know how to make the examina- 
tion and furthermore do not know how to read the 
plates. I am sure that the psychologic effects are 
not the objective of the physician's use of this 
method of examination, although x-ray examina- 
tion to the patient means a great deal. 

X-ray specialists feel that we can find more ex- 
tensive involvement w^ith the x-ray than with 
stethoscopic examinations. The general practi- 
tioner, if we can rely on the statements of patients, 
usually finds, or should find, if he has any ability as 

109 



110 Practical Tuberculosis 

a listener, more with the stethoscope than he actu- 
ally does with the x-ray. 

It is fatal to use this method of examination if 
we cannot understand how to get results, and if 
not used in conjunction with other standard exam- 
inations for tuberculosis. 

My limited experience in x-ray work, coupled 
with the knowledge gained as a result of reading 
the works of the specialists in this department of 
tuberculosis, especially those of Dr. Kennon Dun- 
ham, have taught me the advisability of using 
either or both the fluoroscopic and stereoscopic 
methods of examination in roentgenologic exami- 
nations of the chest. 

The fluoroscope shows motion and also allows of 
the examination of the chest from different angles. 
By using the stereoscope one can definitely locate 
lesions in regard to their three positions in the 
thorax and study abnormal densities in detail. 

The value of x-ray examinations is dependent 
upon the ability of the examiner to determine the 
difference in abnormal densities as compared with 
the normal, and to decide what is the cause of these 
abnormal densities. 

The physician, anticipating the use of the x-ray 
in chest examinations, must memorize these funda- 
mental facts and then must master the technic, 
which includes the qualities of the rays, time of ex- 
posure, and position of the patient relative to the 
tube and plate. Following this, the physician must 



The Use of X-Ray 111 

familiarize himself with the anatomic structures 
which cause the normal densities and be able to 
compare them with abnormal densities. 

Dr. Dunham, by a certain definite technic makes 
a record of the normal variations of density, which 
he calls the norm, and with the same definite tech- 
nic he compares the record of the abnormal densi- 
ties with his norm. When using the fluoroscope, 
he advises the examination of the fields to the left 
and right of the heart and the field between the 
heart and median line, the latter by the rays pass- 
ing obliquely, and the two former fields by the rays 
passing anteroposterior^, and also in the postero- 
anterior direction. The extent of the excursion of 
the diaphragm is noted, and also whether the api- 
ces clear up after cough. In cases of slight lesions 
this method of examination does not easily bring 
out the definite shadows ; these cases should be ex- 
amined with the stereoscope. 

In the stereoscopic examinations of the chest, Dr. 
Dunham insists on (1) perfected apparatus; (2) 
mathematical precision of technic; and (3) binocu- 
lar vision. He explains in detail the exposures, 
position of the patient, and relation of the patient 
and tube, and plate and patient. Then he goes over 
the different anatomic structures and divisions of 
the chest, noticing any abnormal densities, compar- 
ing the findings with his norm, and deciding on the 
cause of the lesion or lesions of density. 



112 Practical Tuberculosis 

The following x-ray plates and histories have 
been furnished by Dr. R. T. Wilson of the Temple 
Sanitarium, Temple, Texas: 

Case 1. — Mr. J. N. H., stockman, age forty-three. 

Family History. — Negative for tuberculosis. 

Personal History. — Has had tuberculosis for four years, had in- 
fluenza one year ago, feels like he has not recovered from it though 
he is now attending to business. 

Present Trouble. — About ftve weeks ago he developed high fever, 
cough and aching in the bones. He thought he had influenza. Now 
has some cough and some fever which is intermittent. Has lost 
only ten pounds in weight, no night sweats or pain in the chest, 
little expectoration. 

Sputum. — Contains pneumococci, diplococci and tubercle bacilli. 

Physical Examination of the Chest. — Heart: regular, rapid, 
sounds clear. Lungs: Numerous rales over both chests anteriorly, 
tubular type of breathing at base of left and apex of right pos- 
teriorly, percussion note diminished along border of scapulae, some 
dullness at apex of left lung anteriorly. 

X-Bay Findings. — -Very extensive mottling throughout the upper 
three fourths of both lungs which is symmetrical in appearance. 
A few calcified glands in each hilus. 

Heart. — Apparently normal size, shape and position. 

Diagnosis. — Pulmonary tuberculosis. 

Case 2. — Mr. D. K. P., insurance agent, age thirty-five. 

Family History. — Five cousins died from tuberculosis. 

Personal History. — Has had some cough practically all of life 
and expectorating some thick mucus. Six years ago while stand- 
ing on the street he had a hemorrhage; went to El Paso for seven 
months where he gained weight and felt fine and had no more 
hemorrhage until two years later when he lost a great quantity 
of blood, in fact, as he thought, came near bleeding to death. He 
has some night sweats, weight about stationary, thinks he has no 
fever, doesn't believe he has tuberculosis but came to hospital for 
treatment for frequent urination and occasional vomiting. 

X-Bay Findings. — Right diaphragm shadow partially obscured 
by pleural adhesions at the base, excursion very limited, the entire 




Fig. 8. — Extensive mottling in upper three quarters of both lungs. 




Fig. 9. — Fine mottling evenly distributed throughout both lungs. 
Costo-phrenie angles clear. 




Fig. 10. — Dense adhesions involving diaphragm both sides, and 
marked infiltration of entire left lung and upper half of right. 
Upper lobe of left is practically consolidated. A fair-sized cavity 
in first right interspace. 




Fig. 11. — Consolidation and cavitation of right lung. Marked 
mottling in left with dense calcareous glands in hilus. 



The Use of X-Bay 113 

right lung quite translucent with two rather large cavities near 
central portion, fair-sized consolidation near the inner border below 
the hilus. The upper lobe of left lung shows marked mottling with 
a few large dense calcareous glands in the hilus. 

Heart — Normal. 

Diagnosis. — Pulmonary tuberculosis with consolidation and cavi-, 
tation. 

Case 3. — Mr. W. H. C, retired merchant, age forty-eight. 

Family History. — Mother living, seventy-four years of age, had 
diagnosis of tuberculosis made thirty years ago. 

Personal History. — Pneumonia five years ago. Twenty years ago 
stomach trouble of two years' duration. Chief complaint at pres- 
ent, continued fever, loss of weight and energy. Four months ago 
was in bed with la grippe twenty days, got up and was clear of 
fever for about a month when he began having fever again, which 
has continued to the present, runs as high as 102° F., highest in 
the afternoon. 

X-Bay Findings. — A fine mottling evenly distributed throughout 
both lungs, the costophrenic angles clear, diaphragm excursion free 
and equal. 

Diagnosis. — Miliary tuberculosis. 

Case 4. — Mr. J. M. Mel., farmer, age fifty-three. 

Family History. — Mother died of tuberculosis at the age of 
thirty-eight; one brother of pneumonia and four aunts died of lung 
trouble. 

Personal History. — Had pneumonia six years ago, never fully 
recovered, gradual loss of strength. During past two years lost 
about fifteen pounds in weight and has coughed at times, is very 
susceptible to colds. 

Physical Examination. — Some diminution of breath sounds over 
entire right chest posteriorly. Some increased whispered voice over 
right apex. 

X-Bay Findings. — Dense adhesions involving diaphragm both 
sides and infiltration of the entire left lung and upper half of right. 
Upper lobe of left is practically consolidated. A fair-sized cavity 
in the right interspace. 

Diagnosis. — Pulmonary tuberculosis. 



CHAPTER XVII 

DETAILS IN THE DAILY TREATMENT OF 
TUBERCULOSIS PATIENTS 

There are many considerations in the daily life 
of the tuberculosis patient, which, when summed 
up, mean a great deal to him in the way of improve- 
ment. A knowledge of physiologic laws and hy- 
giene is necessary in order to master these 
problems. 

A great amount of credit is due to the general 
practitioner who bases his treatment on good com- 
mon sense. It is impossible to consider all the daily 
habits of the tuberculous except in a general way. 

The questions that the general physician is called 
upon to answer are matters regarding the patient's 
room, bathing, clothing, food and drink, entertain- 
ments, and the uses of tobacco and alcohol. 

The best room for a tuberculosis patient is one 
with a southeastern exposure with at least two win- 
dows in the room, preferably one on the east and 
one on the south side, with a sleeping porch on the 
south side. The room should be heated only when 
the patient is sitting up or eating, and at these 
times, if possible, the windows should be open at 
the top and bottom and the patient kept out of any 
strong current of air. 

114 



Details in the Daily Treatment 115 

There should be as small an amount as possible of 
furniture in the room, and that should be furniture 
that can be thoroughly washed. The room should 
be free from all unnecessary fixtures. The patient 
should be supplied with sputum cups which are 
kept covered, and there should be a paper sack 
pinned on the right side of the bed and also some 
paper tissues which the patient uses to cover the 
mouth when coughing. These should be placed in 
the paper sack after being used and burned at the 
end of twelve hours. 

The patient should have a warm bath at least 
once and preferably twice a week. A warm bath 
taken at night causes marked nervousness in some 
cases, hence, a warm bath should not be given at 
night in these cases. 

A patient's hands should be bathed before and 
after each meal and the teeth should be brushed 
after each meal. A glass of hot water before meals 
is a help in digestive disturbances or when the 
patient is taking no exercise. 

The eating and drinking utensils of the tuber- 
culous should be sterilized by boiling; also, the bed 
clothing and clothing of the patient should be 
sterilized before washing. 

The question of diet in the tuberculous has re- 
ceived various answers. It has been thought for a 
long time that milk and eggs in large quantities 
were absolutely necessary in treating the tubercu- 
lous, but it is now thought that a well-mixed diet 



116 Practical Tuberculosis 

of fats, carbohydrates and proteins is the best for 
the ordinary tuberculous person; hence, milk and 
eggs, or forced feeding, should not be resorted to if 
the patient is up to normal weight. 

At times it is necessary to give milk in small 
quantity at frequent intervals to patients with 
marked digestive disturbances, and at the same 
time treat the condition causing the disturbance 
medicinally. 

A patient's clothing should be warm in winter 
and cool in summer, and patients should be 
cautioned about changing clothing or exposing 
themselves in going from hot to cold rooms. A 
patient should try to produce his own heat by eat- 
ing enough, wearing a sufficient amount of clothing, 
and conserving his energy. 

The use of tobacco, coffee and stimulants, as a 
rule, should be prohibited. I am reminded of Dr. 
J. B. McKnight's idea regarding the use of tobacco 
by the tuberculosis patient. Dr. McKnight feels 
that a patient's chance to get better is good or bad 
according to his ability to deny himself pleasures, 
and that if a man cannot give up tobacco, which he 
should if confined to bed or having no exercise, he 
cannot get well. 

The evil effects from the use of tobacco in tuber- 
culosis patients result from the habit of inhaling 
the smoke. To a good smoker, a good cigar is, if 
not contraindicated, a help, especially in quieting 
his mind. 



Details in the Daily Treatment 117 

Regarding the entertainments, the tuberculosis 
patient should learn to deny himself of entertain- 
ment and false pleasures; in a short time he will 
realize how false these so-called pleasures really 
are. He must make a habit of going to bed early 
and of being free from excitement, either as re- 
gards pleasures or worry. 

Patients should be very quiet in the evenings, 
since they are more susceptible at this time to nerve 
stimulation on account of toxemia being more 
manifest. 

A patient must be made to develop his self-con- 
trol and must have determination to get well. In 
short, getting over tuberculosis is a man's game. 



CHAPTEE XVIII 

DIFFERENTIAL DIAGNOSIS IN TUBERCU- 
LOSIS 

Every patient who exhibits symptoms, either 
local, reflex or toxic, simulating tuberculosis, should 
be considered tuberculous until proved otherwise; 
and while we are proving that the symptoms are 
not due to tuberculosis, we should at the same time 
institute the regular treatment which any sick per- 
son needs, such as rest, fresh air, foods, etc. 

There are many infections, especially the focal 
infections, which yield symptoms similar to the 
toxic symptoms found in tuberculosis. There are 
a few conditions that produce reflex symptoms 
similar to those of tuberculosis and there are many 
other conditions that give physical signs similar 
to those accompanying tuberculosis of the lungs. 

The absolute proof of the presence of tubercu- 
losis is in demonstrating the tubercle bacillus, but, 
as a rule, when the tubercle bacillus is demon- 
strable in the sputum the disease is in the ulcera- 
tive stage and the patient is often beyond hope of 
any permanent improvement. 

The physician of the past has been so scientific 
in this respect that he has let his patients become 
far advanced and hopelessly incurable, so that he 

118 



Differential Diagnosis 119 

could say, definitely and finally, that tlie patient 
was tuberculous. 

The presence of the tubercle bacillus is a most 
valuable help in differentiating the nontuberculous 
pulmonary diseases from tuberculosis. When there 
is a large amount of involvement of the lung tissue, 
we naturally expect to find the tubercle bacilli, es- 
pecially when large amounts of sputum are expec- 
torated. If we do not find them in these apparently 
advanced cases, it is necessary to examine the spu- 
tum further, since it is often the case that some 
other organism is causing the disturbance and that 
this condition may be more amenable to treatment 
than the condition due to tuberculosis. 

Often one finds basic cases with quite marked 
physical signs and a large amount of sputum bac- 
teriologically negative for the tubercle bacillus. 
These cases should be proved nontuberculous, and 
the patient should be given treatment while this 
proof is being established. 

Conditions in the chest simulating tuberculosis 
are chronic pneumonia, bronchitis, •streptothrico- 
sis, syphilis, and influenza, as well as conditions 
following organic diseases of the heart, kidneys 
and liver, producing edema of the lungs. 

The physical signs, coupled with x-ray exami- 
nations and observation of the constitutional symp- 
toms and a thorough examination of the sputum for 
the different microorganisms, will in the majority 
of cases clear up the case. 



120 Practical Tuberculosis 

I recall the history of a case that had all the 
symptoms of pulmonary and bone tuberculosis ex- 
cept the positive sputum, and who had had an am- 
putation for a supposedly tuberculous knee. The 
streptothrix was isolated from the sputum, and 
after iodides were administered this patient got 
well. 

Another case, simulating pulmonary tnberculosis 
in the physical signs and constitutional symptoms 
but without positive sputum, made a rapid recov- 
ery after proper attention to the teeth and the ad- 
ministration of an autogenous vaccine made from 
the pus-discharging gums. 

These cases are mentioned to emphasize the neces- 
sity of examining the sputum in cases with marked 
physical signs and a large amount of sputum. The 
physician of the past examined, with negative re- 
sults, the sputum, or what was really saliva, of the 
cases that were not yet ulcerative; he thought that 
the patient with marked symptoms and physical 
signs must have consumption, little dreaming that 
often these symptoms were due to other causes or 
conditions. Syphilis should be excluded in every 
case of pulmonary tuberculosis, or symptoms simu- 
lating pulmonary tuberculosis, and a Wassermann 
test should be done on every patient. 

The cutaneous, subcutaneous or any other test 
with tuberculin is very dangerous and unreliable, 
so far as its application by the general physician 
is concerned. 



CHAPTER XIX 

PROGNOSIS IN TUBERCULOSIS 

Physicians are frequently called upon to express 
their opinion regarding the probable course and 
termination of given cases of tuberculosis. This 
is a very hard problem to decide in the special case ; 
and, in general, we can only consider a few well de- 
fined conditions which usually influence the disease 
one way or the other. 

In talking to patients regarding the course and 
termination of their disease, I emphasize the fact 
that Nature cures tuberculosis by the mechanical 
resistance of the tubercle, by fibrous tissue forma- 
tions, and by the development in the body of sub- 
stances which neutralize the toxins of tuberculosis. 
I also insist that their chance of getting well will 
depend on the amount of rest they take, especially 
in the early and active stages. They should rest 
even more when they go back to their former occu- 
pation, and should remember they can either rest 
or play, but not do both. 

Dr. Charles Minor says that a given case will 
usually turn out the opposite to what you believe, 
considering the prognosis. I have seen this state- 
ment proved time and again. The incipient case 
often dies as a result of some complication, and the 

121 



122 Practical Tuberculosis 

advanced case often becomes quiescent and lives 
for years. 

It is a great mistake for the physician to tell tu- 
berculosis patients definitely that they are going to 
die. It is also a mistake to tell a patient that he 
will absolutely be cured in a certain length of time. 
Usually the physician sets the time for a cure at 
two to three months, and leaves it up to the sana- 
torium physician to answer the question of the pa- 
tient regarding the length of time he must stay in 
the sanatorium or must remain under supervision. 

Only a small number of patients ever become 
cured. I am in the habit of telling patients that 
they will get well for all practical purposes if they 
will follow the advice given them, but that they 
must always consider that they are not able to do 
the things they did before becoming sick. 

Young girls and boys and also young men and 
women, who are at the "spooning" age, are poor 
risks, and I had rather gamble on the outcome of 
the disease in married people with children at home 
than on the unmarried. The former are more deter- 
mined and have better control of themselves. 

Mixed infection organisms, developing in con- 
junction with tuberculosis, render the prognosis a 
little more unfavorable. This is also true regard- 
ing any acute infection, especially where there is 
a marked inflammation of the lungs. 

Heart, liver and kidney diseases are unfavorable 
complications. Disorders of the digestive tract and 



Prognosis 123 

tuberculous infections of the other parts of the 
body are, generally speaking, unfavorable compli- 
cations of pulmonary tuberculosis. 

Dr. Heise has shown that the cases with streaked 
sputum and bacteriologically positive sputum are 
a little less favorable than others. Dr. Trudeau 
found that his patients treated with tuberculin 
lived a little longer than those not treated by this 
agent. 

Persistently low blood pressure and increased 
pulse and temperature, continuing for some time, 
even though the patient is at absolute rest, are un- 
favorable symptoms. Bilateral cases that have 
about the same amount of trouble in both lungs do 
not appear to do as well as the unilateral cases. 

Recent experiments have shown the bad effects 
of worry and fright on the course of tuberculosis. 
As a rule, indoor workers do better than those who 
work outdoors. 

The effort put forth by the patient must be con- 
sidered. It has been often remarked that the 
future of a person's tuberculosis depends more on 
what he has in his head than what he has in his 
lungs. 

Left-sided lesions are usually more dangerous 
than right-sided lesions, due perhaps to the fact 
that the left lung is smaller and has only one inter- 
lobar fissure. .Cavitation in the lower part of the 
lung is more serious than cavitation in the top. 



124 Practical Tuberculosis 

The case with high morning temperature and low 
evening temperature has a poor prognosis, as a 
rule, as does the case with the normal morning 
temperature and high evening temperature. 

As a rule, emphysema and spontaneous pneumo- 
thorax, which usually ends with empyema, are 
grave complications. Pleurisy, if not followed by 
effusion, is not a serious complication. If pleurisy 
is followed by effusion the effusion often becomes 
infected, and therefore should be removed, if of 
any large amount, and air instilled in the pleural 
cavity to take its place. 

Persistent amenorrhea in a tuberculous woman is 
a bad prognostic sign. Pregnancy often flares up 
old lesions, and, occurring in active cases, is very 
unfavorable. 

Cardiorenal vascular diseases often influence the 
disease unfavorably, so far as the tuberculous con- 
dition is concerned; but their presence as compli- 
cations of tuberculosis does not improve their prog- 
nosis to the extent one notes when they occur alone. 
I have frequently seen edema of the lungs, result- 
ing from lack of functionating power as a result of 
tuberculosis, for all practical purposes cure the tu- 
berculous condition, so far as could be ascertained 
clinically, but on the other hand, the resulting 
damage to the heart muscle has resulted in a con- 
dition of chronic invalidism, with poor hopes of a 
very long life ahead. 



Prognosis 125 

Diabetes, if properly treated, has not been of bad 
prognostic significance in my experience, and the 
result of Dr. Landis' research in such cases, treated 
by the Allen method, has been very good. 

The length of time a patient has had tuberculosis, 
without any symptoms of very active trouble, in- 
creases the chance of recovery, while recurrences 
and relapses occurring during treatment are of 
poor prognostic significance. 



CHAPTER XX 

RESISTANCE IN TUBERCULOSIS 

Patients frequently inquire if their resistance is 
good or bad; especially those who have read much 
concerning tuberculosis. We often tell these pa- 
tients that their resistance is good, basing, as a 
rule, our decision on the fact that the patient looks 
strong and rugged and is running a fairly good 
temperature, as well as exhibiting other signs of 
apparent conquering of the invading organisms. 
At other times we tell other patients that their re- 
sistance is poor, especially when the symptoms of 
activity are marked; this is particularly true in the 
cases which have taken treatment for a long time 
without an apparent improvement in their con- 
dition, at the same time showing a large involve- 
ment in their lungs and occasionally other tuber- 
culous complications. There are still other patients 
who have very slight signs in the lungs and at the 
same time run an elevated temperature and rapid 
pulse, even after prolonged treatment, as well as 
being underweight and anemic. 

In either case the fact stands out that resistance 
can be considered only collectively, not knowing 
the virulence of the invading organisms or their 
number. Furthermore, it is evident that at times 
patients, who are very ill, have a better resistance 

126 



Resistance 127 

than those only slightly ill, and that at the same 
time the invading organisms are of different de- 
grees of virulence. 

Corbett cites a case of a man who was married 
three times, each wife dying with pulmonary tuber- 
culosis. The evidence pointed to the probability 
of the man having tuberculosis; upon examination 
he was found to be in the moderately advanced 
stage, without, however, much activity. This is a 
familiar example of the difference in resistance 
due, undoubtedly, to a great extent, to the fact that 
at times the longer a person has tuberculosis the 
better is his resistance, on account of the sensi- 
tizing of the body cells and the mechanical walling 
off of the infected area. One should not necessarily 
expect to find a very ill parent, relative or friend as 
the carrier of the tubercle bacilli in cases that are 
very active. The body has built up the resistance 
of the carrier a great many times ; hence, no suspi- 
cion attaches to him. The apparent good health of 
members of a family in which a case of tuberculo- 
sis has been diagnosed, should not be a reason for 
not examining these contacts. In fact, I have often 
found that the evidence in healthy contacts points 
to the probability of their having been the cause 
of the bacilli keeping up their uninterrupted cycle 
in the active case and probably in many more of 
their associates. While the carrier does not always 
need to take the treatment, still it is best to have 



128 Practical Tuberculosis 

him know his condition, and take the necessary pre- 
cautions to safeguard the health of others. 

As is evident, the resistance of the patient de- 
pends upon the number of infecting bacilli, their 
virulence and the length of time that they have been 
in contact with the tissues. Furthermore the age, 
occupation, habits, environments, intelligence and 
the treatment of the person infected, all have a 
great bearing on the resisting powers. 

The resistance of the human being may be con- 
sidered under the headings of natural resistance 
and acquired resistance. We know that the body 
is protected by the reflexes of sneezing and cough- 
ing which prevent foreign substances from gaining 
access to the air vesicles. Lymphatic glands and 
structures play a great part in helping the body to 
defend itself against the invasion, as do also the 
blood cells, especially the lymphocytes. Normally 
there are different substances in the blood serum 
which are antagonistic to the outside substances. 

Krause has shown how cells protect the body by 
surrounding the tubercle bacilli and forming the 
tubercle by the mechanical wall of defense. The 
development of the tuberculin neutralizing sub- 
stances further prevents the detrimental effect of 
this substance. The physiologic effect of exercise 
and emotion, especially worries and fright, have 
been demonstrated at times to be detrimental to the 
best interest of the patient. 



Resistance 129 

Despite the apparent numerous opportunities of 
the tubercle bacilli to enter the blood stream, the 
fact that the tubercle bacilli are rarely, if ever, 
found in the blood streams* in life shows that be- 
sides the mechanical resistance of the body cells 
the blood contains substances which resist the in- 
vasion of the blood by the tubercle bacilli. "We 
know from their physical effects that there are anti- 
bodies in the blood which we have named bacteri- 
olysins, agglutinins and precipitins. 

It has been commonly considered that a person's 
resistance fell just before death and that the organ- 
isms present in different foci invaded the system 
when the resistance was let down. This has been 
proved true in a number of instances in other in- 
fections, and it would be interesting if the same 
could be proved of the infections of tuberculosis. 
Also, the presence or absence of tubercle bacilli in 
the peripheral blood vessels of very young children, 
who have meningeal tuberculosis would be interest- 
ing to determine. 

It is a well-known fact that latent tuberculosis 
can become active following an attack of measles, 
pneumonia and tonsillitis, and following vacci- 
nation. The presence of other infections besides 
that of tuberculosis determines the resistance to 
this disease. Chronic affections of the nose and 
throat, after being relieved in tuberculosis patients, 
have apparently increased the patient's resistance 
to the tuberculous infection. 



130 Practical Tuberculosis 

The development of the condition known as al- 
lergy results in lowering resistance in the tubercu- 
lous. A small dose of tuberculin can often produce 
this condition, resulting in the focal, local and gen- 
eral reaction of the tuberculosis patient. The prob- 
able chemical action on the focus is a serious one, 
producing by some change, inflammation, and if 
severe, necrosis, which results in a breaking down 
of the mechanical wall of defense and a scattering 
of the disease. It is possible to get the same reac- 
tion following severe exercise, at a certain stage of 
the disease. I have in mind a patient in the incipi- 
ent stage, who thought he would have a good time 
before going to the sanatorium; following a night's 
dancing and carousing, he had a severe reaction, 
which resulted in death. 

The effect of heat, cold and fatigue has been 
demonstrated clinically in all diseases. 

Familiar to all physicians is the advice given by 
the general practitioner of the old school to the 
parents of the chicken-breasted or stoop-shouldered 
youth, to the effect that the boy would develop con- 
sumption. Frequently aged people are seen, who 
were the subject of such a prognosis, and they 
naturally boast that they were doomed to early 
and certain death from consumption, because they 
had these characteristics, but they fooled the doc- 
tor. The older physician based his prognosis on 
observation of the course of the disease in others 
similarly affected, not realizing that the child with 



Resistance 131 

these symptoms was already tuberculous, which ac- 
counted for these symptoms. The worry of devoted 
parents over such a prognosis has probably often 
in itself been a cause of decreasing their own re- 
sistance; and as a result, they have in some cases 
developed the disease, or rather have had their ac- 
tivity increased as a result of this worry. 

By living a life as nearly natural as possible, the 
resistance of the body in tuberculosis is increased. 
The amount of rest that a tuberculosis patient 
takes is a great factor in determining resistance. 
Inheritance of weak constitutions is often the cause 
of poor resistance in the tuberculous. All lives 
should be moulded so that the future generations 
may be free from such inheritances. 



CHAPTER XXI 

PREVENTION OF TUBERCULOSIS 

Broadly stated, prevention of tuberculosis should 
be considered under three headings: (1) Prevention 
of predisposing causes; (2) prevention of infection; 
(3) prevention of further progress of the disease 
in those already affected. 

In view of the recent disclosures regarding the 
incidence of tuberculous infections it is obvious 
that present operations along preventive lines 
should be in the direction of prevention of activa- 
tion of existing foci. Equally important is the pre- 
vention of massive infection from different sources, 
such as milk from tuberculous cattle and the open 
case of tuberculosis. 

The old idea that a person's vitality was low and 
then developed tuberculosis is pretty well done 
away with today. The lowered vitality was prob- 
ably in many cases the result, instead of the cause, 
of the disease ; however, it is quite possible that pre- 
vention of predisposing causes will turn into a mild 
infection what in some cases would be a severe 
disease. 

The number of conditions and factors which are 
possibly predisposing causes of tuberculosis are too 
numerous to enumerate. In general, we can safely 

132 



Prevention 133 

consider a predisposing cause of tuberculosis, any- 
thing that is contrary in its effects or actions to 
the laws of nature. It may be the weakened state 
resulting from other diseases, operations or in- 
juries, or the effect of habits, occupation or environ- 
ments, by which the normal makeup or function, or 
both, of the body is interfered with. 

Different tuberculosis specialists feel that we 
could eliminate tuberculosis from the earth in a few 
years if we could stir up public opinion in regard 
to cessation of promiscuous expectoration. Dr. 
Theobold Smith has shown that tubercle bacilli 
must live and reproduce in animal tissues, and that 
there must be a continuous cycle from person to 
person or from animal to person in order that the 
infections and disease continue. The public, 
through the activities of the medical profession, 
must interrupt this cycle and stop the disease. 

The careless and incorrigible consumptive must 
be dealt with according to the demands of the case. 
The carefully disposed patients must be educated 
in things tuberculous. Sputum must be collected 
in cups which must be covered to keep out flies and 
insects, and these must be burned with the contents. 
Patients should be instructed to cover their mouths 
when coughing and sneezing, and in fact common 
decency should demand that this be a universal re- 
quirement. 

Cattle should be tuberculin-tested. If it is im- 
possible, as occurs in large cities, to determine 



134 Practical Tuberculosis 

whether the cattle from which our milk supply 
comes, are tuberculin-tested or not, the milk should 
be pasteurized. In fact, there are often so many 
opportunities of infection of milk by middlemen, 
that the physician is not going far wrong when he 
insists that all milk for babies be pasteurized. 

All foods, candies and fruits which are not pro- 
tected by proper coverings or by cooking, should 
be considered possible sources of infection; hence, 
one should act accordingly in choosing sweetmeats 
and food for one's children. 

The elimination of handles on the doors of pub- 
lic buildings or public conveyances, as well as ap- 
pliances operated by hands in public places, should 
be strongly advocated. The old drinking cup 
should be eliminated, and our old custom of salut- 
ing others by a shake of the hands should be done 
away with. Kissing, especially the kissing of 
young children on the lips, is probably a frequent 
means of transmitting the bacilli and cannot be too 
strongly condemned. Sterilization of glasses and 
eating utensils, as well as all other things or ar- 
ticles used in common, should be compulsory. In 
some states it is unlawful to serve people in public 
eating houses without sterilizing the dishes after 
each person has finished eating. 

Institution of laws regulating the hours of the 
laboring class and correction of any insanitary 
working or living conditions should be resorted to 
in districts needing these changes. 



Prevention 135 

All those cases that have been in contact with the 
tuberculous should be followed up, and if they are 
infected they must be taught the proper way to 
live and prevent any existing infection from devel- 
oping into disease. 



CHAPTER XXII 

THE ROLE OF THE GENERAL PRACTI- 
TIONER IN TUBERCULOSIS 

A great part of the good to be obtained in the 
antituberculosis work will be due to the efforts of 
the general practitioner. 

In the past, the general practitioner has not 
shown the interest in tuberculosis that he should 
have shown. This lack of interest, in a great many 
instances, has been due to a lack of knowledge re- 
garding the phases of tuberculosis as understood 
today. 

The general physician has gone by the teachings 
of the earlier writers in making his diagnosis, and 
has not relied on natural processes in the treatment 
of his cases. He has, however, given his case tuber- 
culin, serums and vaccines, according to the pop- 
ularity of each remedy, but has failed to keep his 
patient under close supervision. 

A sanatorium is the logical place for a tubercu- 
losis patient for a certain length of time. However, 
most of these institutions have a waiting list which 
is very long, and many of these cases on account of 
ignorance of the disease, gradually become worse 
while waiting to enter an institution. 

The physician would do a great amount of good 
if he would see his patient often, giving him en- 

136 



The Role of the General Practitioner 137 

couragement, and putting him to bed until he could 
enter an institution where he would be under the 
observation of men trained in tuberculosis. It 
would be well also if a physician would have a 
house solely for tuberculosis patients and under the 
supervision of a nurse, trained in the different 
phases of tuberculosis work. 

Education of the patient is very important, and 
every patient should have the benefit of the infor- 
mation found in The Journal of the Outdoor Life. 
and in pamphlets put out by the National Associa- 
tion and the Publicity Department of the various 
State institutions. 

Examination of contacts of tuberculosis patients 
is absolutely necessary. 

The general physician must educate his patients 
in the prevention of infection of their relatives and 
associates. 

The general physician must always be on the 
lookout for tuberculosis in his patient; he must con- 
sider that all of his patients are potentially tuber- 
culous; he must remember that it is impossible to 
standardize tuberculosis, its treatment and prog- 
nosis; he must not expect to find tubercle bacilli in 
the sputum in order to make a diagnosis of tuber- 
culosis. 

Observation of the subjective signs will give him 
the best indications, as a rule, of active tuberculo- 
sis. If he will take note of the tired feeling, the 
nervousness, pain in the chest, spitting of blood and 



138 Practical Tuberculosis 

general conditions below normal, lie will be able to 
diagnose his case as tuberculosis. By instituting 
treatment with Nature's processes — rest, fresh air, 
sunlight and nourishing foods, coupled with con- 
stant encouragement and education of the patient, 
and at the same time teaching him how to lead a 
natural life, he will achieve wonderful results, and 
he will be impressed with the fact that Nature 
cures tuberculosis, if assisted. 

Furthermore, while we are beginning to know 
a great deal about tuberculosis, still we have not 
yet scratched the surface of the great question. It 
is probable that we shall not know of a specific 
remedy for tuberculosis until we know absolutely 
all the changes that take place in the body of those 
cases that have, for all practical purposes, re- 
covered from the disease. 

It seems almost as if tuberculosis was inflicted 
on the people as a punishment for their sins in not 
living natural lives; hence if there is one disease 
that should make people stop and think about the 
wonderful remedies of Nature — that disease is 
TUBERCULOSIS. 



CHAPTER XXIII 

THE CONTROL OF TUBERCULOSIS 

There are many problems, sociologic, economic, 
medical, legal, political and sentimental, which con- 
front us when we consider the control of tubercu- 
losis. 

In order that these problems may be met so that 
their solution will be successful, or at least more 
successful than is the case at present, it will be 
necessary to educate everyone in the different 
phases of tuberculosis, its causes and effects. 

Cooperation is absolutely essential, and those 
who fail to cooperate for the common good or those 
who obstruct the good work should be dealt with 
by the strong arm of the law. 

Statisticians have shown that about 200,000 
people die annually in the United States from tu- 
berculosis. 

In the demonstration work at Framingham, 
Mass., it has been found that 20 cases of tubercu- 
losis are present where there is one death and that 
9 of these cases need sanatorium treatment. 

It follows then that there are in the United States 
4,000,000 cases of tuberculosis and out of this num- 
ber 1,800,000 need sanatorium treatment. Further- 
more, it was shown in the von Pirquet survey at 
Framingham, that 50 per cent of the children at 

139 



140 Practical Tuberculosis 

the age of six years had a positive skin test. Post- 
mortem examination of a number of people dying 
of all causes showed a very high percentage (97) 
of tuberculous lesions. It follows that practically 
every adult person has had an infection or disease 
of varying severity, and that 50 per cent of all 
children at the age of six years have been infected. 
This percentage would increase with the age of the 
children. 

Eeports show that cattle and hogs are frequently 
infected with bacilli. Food products from these 
animals have been found to contain many virulent 
bacilli. What is being done to overcome these con- 
ditions ? 

Many tuberculosis sanatoriums, dispensaries and 
clinics have been opened. Many laws have been 
made regarding the careless and incorrigible con- 
sumptive and much educational work has been 
done. 

The dispensaries do not go out after the tuber- 
culosis patient. The sanatoria, as a rule, are filled 
with advanced consumptives, and too often under 
the supervision of politically interested boards of 
management and superintendents. Many, or at 
least a few, of the private sanatoria have for their 
sole object the making of money. The laws which 
are on the statute books are not enforced. 

Antituberculosis work is not standardized. Some 
states are building numbers of sanatoria to be filled 
with the advanced consumptives after these con- 



The Control 141 

sumptives have already infected all tlieir relatives. 
Other states are making poor attempts to run what 
few institutions they have. There are some states 
that are doing very well, so far as efficiency is con- 
cerned. 

Tuberculosis cannot be controlled by treating it; 
hence, it is our duty to prevent it. 

Some authors have suggested that we should not 
eradicate tuberculosis, because then the immunity 
of the human race to tuberculosis would eventually 
be lost. Even if it were possible to eradicate tuber- 
culosis, we could still grow tubercle bacilli in the 
incubator and immunize people at stated intervals 
with the bacilli. 

Education of the public is the best means of con- 
trolling tuberculosis. Public opinion must demand 
that all necessary steps be taken to stop the spread 
of tuberculosis. 

Every branch of public health is concerned in 
the control of tuberculosis. No physician would 
contend that tuberculosis makes one more suscep- 
tible to measles or influenza ; but he would assert 
that measles and influenza stir up a tuberculous 
focus. 

Every person should be considered potentially 
tuberculous and should undergo thorough physi- 
cal examinations once or twice each year, or more 
often, in case there are indications of lung disease. 
Those who have had contact with tuberculous per- 
sons must be more watchful. Suitable work must 



142 Practical Tuberculosis 

be found for the tuberculosis patient. He must re- 
alize that he will never be absolutely well, but must 
always take care of himself and by so doing will 
live the rest of his natural life. 

Adulterations of Nature 's processes are often the 
predisposing causes which activate a healed lesion. 
Children should be instructed regarding the make- 
up and the function of their bodies. They should 
know what are the harmful effects of fatigue, poor 
air, lack of food and clothing. 

The poor man and woman and child must not 
only be given a chance to live in the right way, but 
they must be taught how to live, and be made to 
live rightly. 

In the mad rush for the "Almighty Dollar" the 
human race has lost sight of its object in living. 
The rich man, in his egotism, has worked the poor 
man so that he, the rich man, may have money with 
which, in a great many instances, he lives an un- 
natural life, while the poor man is also compelled 
to live an unnatural life, deprived of fresh air, good 
food, rest and pleasant hygienic surroundings. 

As a result of this mad rush, our bodies suffer, 
and Nature remonstrates in some cases, by stirring 
up an infection of the tubercle bacilli. If we 
hearken in time we shall be saved, but if we know 
not what to hearken for, we shall be lost. 



CHAPTER XXIV 



HISTORY TAKING 

A well-taken history is a great help in the final 
summary of a case. The history not only brings 
out the past symptoms and present complications, 
but it also serves as a guide for the physician in 
that he does not miss important details in the case. 

A physician may feel that it takes too long to 
make a history in these cases, but he should make 
it worth his while. He will find it much easier by 
referring to the history to advise the patient, on 
future visits. 

A card with the following to be filled in will 
suffice : 



Name 


Eace 


Occupation 


Address 


Birthplace 


Civil condition 


Date of birth 


Sex 
Family History 




Father 


Mother 


Brothers 


Sisters 


Consort 
Previous History 


Children 


Pneumonia 


Pleurisy 


Eheumatism 


Grippe 


Typhoid 


Malaria 


Appendicitis 


Diabetes 


Throat disease 


Nasal disease 


Genitourinary 


Convulsions 


Hemorrhoids 


Operation; Injury 


Habits 


Skin disease 


Smallpox 


Paralysis 


Deformities 


Childhood diseases 





Present Illness 

Date and period of exposure. 

Preceding associates (whether relatives or not) 

First presumable evidence. 

First demonstrable evidence. 

143 



144 



Practical Tuberculosis 



Symptoms 


(date of appearance) Onset (date) 


Hemorrhage 


Number and amount 


Fever 


Chills 


Pleurisy 


Indigestion Insomnia 


Tired feeling 


Night sweats Dyspnea 


Loss of appetite 


Diarrhea 


Loss of weight 


Hoarseness 


Loss of strength 


Sinuses 


Cough 


Enlarged glands 


Expectoration 


(amount and character) 


Previous treatment 






Physical Examination 


General development 


Nourished Symmetry 


Color of mucus mem 


- 


brane 


Teeth Tongue 


Eyes 


Pupils Hair 


Fingers 


Edema Cyanosis 


Heart 


Nose, Pharynx, 




Larynx 


Height 


Weight 



It is best to chart the signs found at each exami- 
nation and the following may be used: 

Charting Signs 

lb. Interrupted breathing. 
Bvb. Bronchovesicular breathing. 
Bb. Bronchial breathing. 
C. Cavitation. 

Bales may be small or large and are designated 
on the chart by small and large dots. 

Dullness and flatness are designated by lines 
drawn through the flat or dull area. The thickness 
of the lines denotes the amount of dullness. 

Bronchial rales, sibilant and sonorous may be 
designated by a "V" over the area where these 
are found. 



CHAPTER XXV 

STAINING THE TUBERCLE BACILLI 

A small amount of the cheesy looking sputum is 
applied to the glass slide. The smear is allowed 
to dry after it has been rubbed out to a thin film 
and then the following procedure is followed: 

1. First flood the slide with carbolfuchsin and 
heat gently over the flame until film seems deeply 
stained. 

2. Wash and decolorize with a 2 per cent solution 
of hydrochloric acid in 80 — 95 per cent alcohol. 
It is well to decolorize until the thinner portions of 
the film show no red color. 

3. Wash in water. 

4. For a contrast stain use methylene-blue. 

5. Wash and examine. 

The bacilli are shown up as red rods with a blue 
background. This is the Ziehl-Neilsen stain. 



145 



CHAPTER XXVI 

DON'TS FOR THE PHYSICIAN 

1. Do not wait to find tubercle bacilli in sputum 
before making a diagnosis of tuberculosis. 

2. Do not tell the patient to "go West and rough 
it." Send him to a sanatorium. 

3. Do not be afraid to give the patient too much 
rest. 

4. Do not fail to instruct the patient and his rel- 
atives in methods of preventing the infection of 
others. 

5. Do not tell the patient he will be well in a 
short time. 

6. Do not go by the chest signs alone, but remem- 
ber that the patient who is apparently very ill, may 
have the smallest amount of involvement in the 
lungs. 

7. Do not give medicine unless absolutely neces- 
sary. 

8. Do not overfeed. 

9. Do not permit visitors in toxic cases. 

10. Do not forget that Nature has cured many 
tuberculous persons, and that medicines, vaccines _ 
and serums have killed more patients than they 
have cured. £■ 

146 



CHAPTEE XXVII 

MARRIAGE IN TUBERCULOSIS 

The consideration of marriage and the factors in- 
volved, both preceding and following, is of great 
importance to the tuberculosis patient. 

It is impossible to make any dogmatic statement 
that will cover every case in question. It is pos- 
sible to consider, in a general and practical way, the 
reasons for and against marriage in the tubercu- 
losis patient. 

The tuberculous husband and wife must be con- 
sidered, and most seriously the health of the off- 
spring of tuberculous parents. 

To deprive tuberculous people of the most won- 
derful provision of Nature, in every instance, is 
criminal. On the other hand, to permit the suffer- 
ing that ensues as a result of some marriages 
among the tuberculous, is likewise criminal. 

If tuberculosis patients are to live on physiologic 
lines, affection that is created by beauty or some 
other condition must be given them. 

The stimulating effects of tuberculosis patients, 
resulting from the association of the sexes, is very 
marked. Association of men and women patients 
in a sanatorium, however, should not be permitted 
to any great extent. Sanatorium patients have too 
much time to think, and if the patients associate 

147 



148 Practical Tuberculosis 

too closely affections predominate over common 
sense to the extent that, instead of taking rest, they 
are really exercising and, in a great many in- 
stances, apparently losing all the judgment they 
once possessed. 

Occasionally the patients are jilted lovers. In 
case their love was sincere, they are very poor risks 
from the standpoint of prognosis. Continual 
brooding over their unfortunate love affair lowers 
their resistance in most cases. 

Tuberculosis is practically never inherited. If 
it were so, it would be necessary for the bacilli to 
be in the spermatozoa or ova. Occasionally, with- 
out doubt, infection of the embryo takes place as a 
result of the entrance of tubercle bacilli into the 
uterus. These bacilli may originate from the male 
or female organs of generation, but only if the 
organs are tuberculous. 

In far advanced tuberculosis of the mother, in- 
fection of the fetus can take place through the 
circulation. 

One may recall the so-called " Danish System" of 
caring for the calves of tuberculous cattle. By iso- 
lating the calves of tuberculous cattle and feeding 
them milk from nontuberculous cattle, it was pos- 
sible to prevent infection to a great extent, showing 
that infection, as a rule, was not in utero. 

Every babe born of a tuberculous mother should 
be removed from the mother's presence and fed 
artificially. 



Marriage 149 

Statistics show that the incidence of tuberculosis 
among children of tuberculous parents is only 
slightly increased over that of children from well 
people. 

Eemembering the foregoing consideration it is 
permissible to dismiss the subject of the offspring. 
The father, if tuberculous, usually does as well as 
if he is single. The main consideration is that of 
finances. If he is not compelled to overwork or 
worry he will undoubtedly get along better than if 
he were single. 

The health of the mother is of the most concern. 
As a rule, the health of the tuberculous mother 
depends upon finances. If she can take the neces- 
sary amount of rest and have the necessary amount 
of help, she will do well in ordinary circumstances, 
but if she is an advanced case of the ulcerative 
type, she will probably not do well under any con- 
ditions. If she is an active case of any stage, preg- 
nancy will invariably increase the disease in the 
lungs. 

Norris is of the opinion that a tuberculous 
mother may have one child and get along all right 
but that the second pregnancy is more harmful and 
the third often fatal. 

Therapeutic abortion in tuberculosis has been 
performed too often. The best judgment possible 
must be used in these cases, but no dogmatic state- 
ments must be made to the effect that tuberculous 



150 Practical Tuberculosis 

persons should not marry, or that they should not 
have children. 

Without doubt there are many tuberculous 
mothers who have a number of children without 
increasing their disease. It is also possible that, in 
many instances, there has been an improvement in 
the diseased lungs, following pregnancy. 

On the other hand, we can trace many deaths 
from tuberculosis in women, as due to the lowered 
resistance resulting from too many and too fre- 
quent pregnancies, with their consequent increased 
worry and work. 



CHAPTER XXVIII 

SUMMARY 

A summary of the ideas and experiences ex- 
pressed in this book regarding the diagnosis, pre- 
vention and treatment of tuberculosis necessitates 
a repetition of what has been written before in 
many other books. It is only by insistence upon 
and repetition of the obvious that progress is made 
in any undertaking. The part that the physician 
and the layman should play in ridding the world 
of this disease is very evident. The lack of cooper- 
ation, due to the lack of knowledge of the funda- 
mental principles of tuberculosis, must be overcome 
by education. The part that prevention plays is 
the greatest part. "We must prevent the transmis- 
sion of bacilli by every possible means known to 
scientists. This will be relatively easy if the people 
are educated and made to protect the health of 
others. Those cases that are already infected, 
must be prevented from developing activity by 
changing their present methods of living. People 
must have some other object in life besides making 
money. Following the teachings of the Old Testa- 
ment will be of the greatest help. A better knowl- 
edge of our bodies and the functions of the dif- 
ferent organs will show us the need for using 
Nature's remedies — fresh air, food, rest and sun- 

151 



152 Practical Tuberculosis 

shine, in larger doses and for longer periods of 
time. If tuberculosis is to be prevented, the appar- 
ently well people (who are, nevertheless, already 
infected) must be looked after, and the same rem- 
edies of Nature, although perhaps in smaller doses, 
as are used in treating the manifestly tuberculous, 
must not be neglected. 

Doing away with false pleasures and adulter- 
ations of Nature's processes will be a great step in 
prevention. If rest, fresh air, food and sunshine 
will cure tuberculosis, it stands to reason that the 
same processes will prevent the activation of any 
foci in the bodies of people who are apparently well. 
The death-traps, known as factories and mills, must 
be looked into. Dwelling houses in cities must be 
changed. Better facilities for the life of the poor 
man must be provided in order to get the best re- 
sults in preventing tuberculosis. 

Eegarding diagnosis, it is absolutely necessary 
for the layman and the general physician to discard 
the old symptoms of night sweats, profuse cough 
and expectoration, which they have considered in 
making their diagnosis of tuberculosis, and in their 
place substitute the symptoms which we have 
learned are those of early active trouble, such as 
a tired feeling, slight fever, slight loss of appetite, 
spitting of blood, cough and expectoration, pain in 
the chest, rapid pulse, nervousness and indigestion. 
Laymen and physicians must be more suspicious of 
tuberculosis, and a physical examination once or 



Summary 153 

twice each year is best for everyone. The exami- 
nation must not be a perfunctory affair, but must 
be thorough and systematic. By all means, the 
physician should not expect to find tubercle bacilli 
in the sputum before he makes a diagnosis of tuber- 
culosis. This idea has been the cause of the great 
mortality in tuberculosis. 

Considering treatment, it must be realized that 
Nature cures tuberculosis with her processes of 
rest, fresh air, food and sunshine, and that the 
doctor helps Nature if he understands her warnings 
and knows what to do. A tuberculosis patient will 
often overdo matters ; then Nature gives the patient 
a warning to go slow by elevating the temperature, 
increasing the rapidity of the pulse, and increasing 
the severity of all other manifestations according 
to the amount of overexertion. 

Medicines, serums, vaccines, tuberculins or ex- 
ternal applications have practically no place in the 
treatment of tuberculosis. Much harm has been 
done in tuberculosis patients by overtreating them 
with the a.bove remedies. 

Tuberculosis is universal and also relative. 
Many cases have been accidentally diagnosed. 
These cases, if inactive, should not be made to lie 
flat on their back for six months or a year. They 
should, however, be advised how to live so that 
they will not reactivate their healed foci. 

It must be remembered that tuberculosis is the 
most curable of all chronic diseases in case an early 



154 Practical Tuberculosis 

diagnosis is made, and early treatment with Na- 
ture's processes is instituted. 

It must also be remembered that a person who 
has contracted tuberculosis is never absolutely 
well, but that for all practical purposes he can live 
the rest of his natural life if he will cut out false 
pleasures and live as Nature meant him to live. 






INDEX 



Abnormal respirations, 36 
Action of tuberculin, 104, 106 
Active tuberculosis, 23 
Adults, prevention in, 132 
Advanced tuberculosis, 13 
Adventitious sounds, 37 
Advice, 61 
Air passages, 54 
Altitude, 77 
Amphoric whisper, 38 
Anatomy of lungs, 54 
Artificial pneumothorax, 96, 97, 
98, 99, 100, 101, 103 



Bartlett, P. C, 31 

Baths, 62 

Bone tuberculosis, 79 

Bromides, 67 

Bronchial glands, 48, 49 

Bronchial respiration, 36 

Bronchophony, 38 

Bronchovesicular respiration, 38 

Brown, Lawrason, 31 



Caseation, 47 

Cause of tuberculosis, 19 

Cavernous rales, 38 

Cavity formation, 50 

Charting of findings, 144 

Chemistry of respiration, 59, 60 

Chest symptoms, 19 

Childhood infection, 31 

Chilled body, 18 

Classification of tuberculosis, 

42, 45 
Climate in tuberculosis, 92 



Colds, 79 

Complement fixation, 31 
Complications, 79 
Concentration, 34 
Conheim, 19 
Consumption, 13 
Consumptive, 13 
Control, 139 
Corbett, 127 
Cornet, 20 
Cornick, Boyd, 46 
Cough, 59, 68, 69 

treatment of, 68, 69 

types, 68, 69 



Death in tuberculosis, 29 
Definition of classification, 42, 
45 

of climate, 92 
Details in treatment, 114 
Detection of chest sounds, 27 
Determination, 117 
Diagnosis, 23 

by general practitioner, 147 

childhood, 23, 30 
Diet, 76, 115 

Differential diagnosis, 118 
Diminished voice transmission, 

34, 37 
Discovery of tubercle bacillus, 

19 
Dry laryngeal rales, 37 
Dullness, 34, 37 



E 



Effusion, 100 
Ehrlich's theory, 47 
Elimination, 64, 67 



155 



156 



INDEX 



Empyema, 79 

Energy, 53 

Entertainments, 117 

Ether, 79 

Exaggerated respiration, 36, 37 

Exercise, 87 

Expectoration, 98 



Fatigue, 53 
Feeble respiration, 36 
Fibrosis, 51 
Flatness, 37 
Fluoroscope, 109, 114 

G 

Gabbett's stain, 19 
General practitioner, 146 
Germicidal agents, 20 
Glandular tuberculosis, 48, 49 
Graduated exercise, 87 

H 

Habits, 119 

Hawes, John B., 50, 74 

Heat of body, 75 

Heise, F., 123 

Hemorrhage, 69 

History of tuberculin, 104 

of tuberculosis, 13 
Hospital treatment, 67 
Hot climate, 92 



Incipient tuberculosis, 45 
Indeterminate rales, 39 
Indication for artificial pneu- 
mothorax, 96, 103 
Infection, 19 
Inspiration, 60 
Inspired air, 58 
Internal respiration, 60 
Intestinal tuberculosis, 79, 80 
Iron, 66 



Jerking inspiration, 37 

K 

Koch, Robert, 14 

Knopf, Adolphus, 30 

Krause, Allen K., 20, 29, 46, 50 



Laennec, 14 

Lapham, Mary, 49 

Laryngeal tuberculosis, 49, 69 

Latent rales, 30 

Laughing, 59 

Local symptoms, 19 

Lungs, 54 

M 

Marriage in tuberculosis, 147 
Meningeal tuberculosis, 79 
McKnight, J. B., 116 
Method of examination, 24, 26 

control, 140 

infection, 20, 49 

pneumothorax treatment, 96 

prevention, 113 
Minor, Charles, 121 
Mixed infection, 47, 123 
Modified respiration, 58 

N 

Nature 's processes, 64 
Nerve excitants, 61 
Night sweats, 75 
Normal chest, 36 
respiration, 36 
Norris, 149 
Number of bacilli, 19 
Nursing, 67 

O 

Object of exercise, 87 

of rest, 87 
Observation in diagnosis, 29 
Opiates, 64 
Optimism, 67 






INDEX 



157 



Pain in chest, 73 

Palpation, 20 

Pathology, 46 

Patient's room, 115 

Pectoriloquy, 38 

Percussion, 30 

Peritoneal tuberculosis, 79 

Petroff-, 31 

Physical signs, 33, 37 

Physiology of tuberculosis, 53 

Pleural inflammation, 45, 47 

Position of patient, 115 

Predisposing causes, 19 

Predisposition, 19 

Pregnancy, 147 

Prevention, 132 

Production of physical signs, 

33 
Prognosis, 122 
Prolonged expiration, 37 
Puerile respiration, 37 

Q 

Qualities of sound, 35, 36 
Quiescent, 42, 45 

E 

Rales, coarse mucus, 37 

crepitant, 37 

dry laryngeal, 37 

fine mucus, 37 

indeterminate, 37 

moist laryngeal, 37 

sibilant, 37 

sonorous, 37 

subcrepitant, 37 
Rathburn, Dr., 43 
Reflex symptoms, 33 
Renal tuberculosis, 79 
Resistance, 126, 129 
Resonance, 38 

Respiration, physiological, 37 
puerile, 37 
senile, 37 
Respiratory sounds, 37, 45 



Rest, 66 
Run down, 19 



S 



Sanatorium treatment, 64 

Sigh, 59 

Smith, Theobald, 133 

Snoring, 59 

Sobbing, 59 

Spontaneous pneumothorax, 79, 

84 
Sputum examination, 145 
Staining of tubercle bacilli, 19, 

45 
Stereoscope, 109 
Stool examination, 29 
Subjective symptoms, 23 
Symptoms of tuberculosis, 23 



Tonsil infection, 79 
Toxemia, 65 
Tracheal respiration, 36 
Transmission of tuberculosis, 

20, 24 
Treatment of tuberculosis, 64 
Trudeau, E., 123 
Tubercle, 13, 47, 122 
Tubercle bacillus, 21, 24, 28 
Tuberculin, 104 

in diagnosis, 30 
Tuberculosis, 14 

experimental, 14 

of kidneys, 79 
Tuberculous pneumonia, 79 
Types of bacilli, 19 

of cough, 68, 69 

of hemorrhage, 69, 70, 71 

of pain, 73, 74 



Use of x-ray, 109, 114 

V 

Vaccines, 108 
Value of skin test, 31 
Vesicular respiration, 57, 58 
Villemin, 14, 19 



158 



INDEX 



Virulence of bacilli, 19 
Visitors, 90 
Voice transmission, 38 
Von Pirquet survey, 31 

W 

Webb's experiment, 17 
Wilson, E. T., 112 
Worry, 54 



X-ray, 109, 114 

Y 

Yawn, 59 

Z 

Ziehl-Neilsen stain, 20, 145 



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